Escolar Documentos
Profissional Documentos
Cultura Documentos
in General Practice
John Davies
John Davies
This work is copyright. It may be reproduced in whole or part for study or training purposes subject to the inclusion of an acknowledgment of the source and no commercial usage or sale. Reproduction for purposes other than those indicated above requires the written permission of the author. Commonwealth of Australia First published February 2000 Revised August 2002 and June 2003 ISBN 0 642 41587 0 P3-XXXX (0108) The opinions expressed in the manual are those of the author and are not necessarily those of the Commonwealth Department of Health and Ageing. Edited and designed by Kathleen Phelps Additional copies may be obtained from: Publications Officer Mental Health and Special Programs Branch Commonwealth Department of Health and Ageing GPO Box 9848 CANBERRA ACT 2601 Telephone: 1800 066 247 Facsimile: 1800 634 400 or the Primary Mental Health Care Development Liaison Officers (DLOs) in each state and territory Division of General Practice State Based Organisation (SBO). Suggested references:
National Mental Health Strategy, Primary Mental Health Care Initiative, Divisions of General Practice, Primary Care Psychiatry: The Last Frontier, Joint Consultative Committee, Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care, February 2000
iv
Hickie I, Scott E, Morgan H, Sumich H, Naismith S, Davenport T, Hadzi-Pavlovic D, Gander J. A Depression Management Program: Incorporating Cognitive-Behavioural Strategies. Box Hill: Educational Health Solutions, 2000.
vi A Manual of Mental Health Care in General Practice
Acknowledgments
My special thanks to members of the Logan Consumer and Carer Action Group, Colleen Chard, Laurel Sandilands and Linda Urquhart who wrote the chapter, Consumer and Carer Perspective. I am most grateful to Geoff Riley for writing the foreword and for his many helpful comments made after reviewing an earlier version of the text. I thank the following for their comments on earlier drafts of the manuscript: Geoffrey Beames, Michael Beech, Jeremy Butler, Gerard Byrne, Monica des Arts, Jenny Easton, Joshua Geffen, Bruce Gynther, Ian Hickie, Tom Hogan, Brian Kelly, John McGrath, Wendy Moody, Glenys Powell, Nigel Prior, Josephine Sundin, Frank Varghese, Warren Ward, Stephen Wild, Kaye Wilhelm and Leonie Young. I also thank Brian Kelly for his many expert comments. My thanks to psychiatrists from the Logan Beaudesert Mental Health Service and staff of the Logan Area Division of General Practice for their support in the case-conferencing project. In particular, I am grateful to Debbie Croyden, project officer with the Division and to Stephen Wild and Wendy Moody who acted as general practitioner coordinators for the project. As case manager for the shared care project, Bernadette Opertowski has demonstrated how effective this model of service delivery can be. My thanks to Jeremy Van Dorsselaer, librarian for the Logan Beaudesert Health District, for his invaluable assistance. My gratitude to Monica des Arts and Brett Emmerson, present and past Directors of the Logan Beaudesert Mental Health Service, for supporting and participating in the project. Queensland Health and the Commonwealth Department of Health and Ageing have funded this publication. Grateful acknowledgment is made to the following for permission to quote material in copyright: the Department of Health and Community Services (Victoria) for tables from Psychotropic Drug Guidelines, published by the Victorian Medical Postgraduate Foundation Therapeutics Committee (1995) Families International Publishing Pty Ltd for a table from Every Parents Group Workbook by Carol Markie-Dadds, Karen MT Turner and Matthew R Sanders, (1997) Ian Hickie for permission to publish tables and figures from A Depression Management Program for Patients and Their General Practitioners by I Hickie, E Scott, C Ricci, C Hadzi-Pavlovic and T Davenport, published by Educational Health Solutions, (1997) The British Journal of Psychiatry for reproduction of the Edinburgh Postnatal Depression Scale devised by J L Cox, J M Holden and R Sagovsky, published in the British Journal of Psychiatry (1987; 150:782-786) Stuart Baker for the use of a table from Drug Wise (1997; 21:46) the US Department of Health, Education and Welfare for reproduction of the Abnormal Involuntary Movements Scale (AIMS) from W Guy ECDEU Assessment Manual for Psychopharmacology Washington DC (1976) GJ DuPaul and the Guilford Press for permission to reproduce the ADHD rating scale from GJ DuPaul, TJ Power, AD Anastopoulos, R Reid ADHD Rating Scale-IV: Checklists, Norms and Interpretation New York: Guilford (1998) John F Greden, Editor in Chief, Journal of Psychiatric Research for permission to reproduce the Mini-Mental State examination from MF Folstein, SE Folstein, PR McHugh MiniMental State: a practical method for grading the cognitive state of patients for the clinician, Journal of Psychiatric Research (1975; 12: 189-198). Most of all, I thank Grace Groom, Director of the Queensland Divisions of General Practice Mental Health Support Strategy, without whose drive, support and humour the book would never have been written.
A Manual of Mental Health Care in General Practice vii
Contents
Foreword to revised edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Preface to revised edition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii Introduction .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Chapter 1
Working with district mental health services .. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 The burden of mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Mental health care in general practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 District mental health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Partnerships in mental health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 An example of collaboration between general practitioners and a district mental health service . . . . . . . . . . . . . . . . . . . . . . 6
Chapter 2
Mental health assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Eight principles of the psychiatric interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 The psychiatric assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Psychiatric history . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Mental state examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Diagnosis and formulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Chapter 3
Suicidality and dangerousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Assessment of suicidality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Dangerousness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Chapter 4
Transcultural mental health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Culture and mental illness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 The interpreted interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Indigenous mental health issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
Chapter 5
Family and marital problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Family problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Marital counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Chapter 6
Crisis intervention, counselling and structured problem solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Crisis intervention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52 Counselling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53 Structured problem solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Chapter 7
Grief counselling .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Bereavement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Breaking bad news . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
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Chapter 8
Supportive psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Techniques of therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68 Problems in supportive psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
Chapter 9
Behavioural treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Classical conditioning (associative learning) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Operant conditioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Behavioural approaches to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Chapter 10
Cognitive behavioural therapy (CBT) .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83 Treatment techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84 Indications for cognitive behaviour therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Chapter 11
Interpersonal psychotherapy (IPT) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 The conduct of IPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 Techniques of therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96 Training in IPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Chapter 12
Dynamically informed therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Impulse control . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Self-esteem . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Shame and guilt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100 Quality of relationships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Defence mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101 Developmental stages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Regression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104 Repetition compulsion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Two interventions derived from dynamic psychotherapy . . . . . . . . . . . . . . . . . . . . 105 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Chapter 13
Pharmacological treatments .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Antipsychotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 109 Antidepressants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Antimanic drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Anxiolytics and hypnotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Chapter 14
Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 127 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Post-partum disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
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Chapter 15
Anxiety disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141 Generalised anxiety disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 Panic disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Agoraphobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Specific phobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Social phobia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Obsessivecompulsive disorder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147 Post-traumatic stress disorder (PTSD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Chapter 16
The relationship between physical and mental illness . . . . . . . . . . . . . . . . . . . 151 Psychiatric symptoms that occur in response to having a physical illness . . . . . . . . . 151 Physical disorders that can cause psychological symptoms . . . . . . . . . . . . . . . . . . . . 151 Mental disorders that present with physical symptoms . . . . . . . . . . . . . . . . . . . . . . 152 Physical illness that occurs indirectly as a result of having a mental illness . . . . . . . . 152 Transference and countertransference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Chapter 17
Organic mental disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Delirium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156 Other mental disorders due to general medical conditions or substance use . . . . . . . 161
Chapter 18
Substance abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 167 Complications of the abuse of specific substances . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Chapter 19
Somatoform disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 Unexplained physical symptoms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Prolonged fatigue syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Hypochondriasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Chapter 20
Sexual dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Ethical issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 Assessment of sexual problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 186 Formulation of sexual problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187 General approaches to treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190 Diagnosis and treatment of specific conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194 Referral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 199
Chapter 21
Trauma, memory and dissociation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Effects of trauma on memory . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204 The false memory debate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206
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Chapter 22
Psychotic disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Background . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Assessment and diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211 Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 215
Chapter 23
Personality disorders .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223 Cluster A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Cluster B . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 225 Cluster C . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230
Chapter 24
Child and adolescent mental health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Developmental considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Social context . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 233 History and examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 234 Specific conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235 Child abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257 Advice on parenting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Goals for childrens behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Chapter 25
Doctors mental health .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Epidemiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 265 Causes of doctors mental health problems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 266 Barriers to care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Treatment and prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267 Self-care for general practitioners . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Chapter 26
Consumer and carer perspective .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269 Living with mental illness consumers and carers experiences . . . . . . . . . . . . . . . 269 What is the most important thing to tell general practitioners? . . . . . . . . . . . . . . . . 269 What is it like to have a psychotic illness? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 270 How did others react towards me? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 271 How did general practitioners react towards me? . . . . . . . . . . . . . . . . . . . . . . . . . . 272 What helped? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 272 What did not help? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274 Further information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Training course . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Essential texts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Reference texts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Appendices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 278 Appendix 1 Example of a SPHERE Questionnaire . . . . . . . . . . . . . . . . . . . . . . . 278 Appendix 2 Mini-Mental State Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 279 Appendix 3 Structured problem solving . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 281 Appendix 4 Controlled breathing exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Appendix 5 Progressive muscular relaxation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
A Manual of Mental Health Care in General Practice xi
Appendix 6 Self-hypnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284 Appendix 7 Daily activity schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 Appendix 8 Treatment of agoraphobia by exposure to the feared situation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286 Appendix 9 Recording feelings, automatic thoughts and the situations in which they arise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 287 Appendix 10 Abnormal Involuntary Movement Scale (AIMS) . . . . . . . . . . . . . . . 288 Appendix 11 Treatment of sleep disturbance . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Appendix 12 Edinburgh Postnatal Depression Scale (EPDS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 292 Appendix 13 The ADHD rating scale . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 295 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
xii
Introduction
This book grew out of the collaboration between the Logan-Beaudesert Mental Health Service and the Logan Area Division of General Practice on the case-conferencing project, a series of eight seminars that aim to improve general practitioners knowledge of the mental disorders that they commonly treat and to increase their familiarity with how the service functions. I hope that it is a useful resource for similar projects. In writing the book I have tried to combine the advantages of a manual and a textbook. I hope that it provides easily accessible information on the assessment and treatment of the mental disorders that general practitioners see, but in more depth than might usually be found in a manual. One of the challenges of treating mental health problems in general practice is that as many as 50 per cent of them do not meet the criteria for any specific diagnosis. Moreover, people often present with a complex combination of physical and mental health problems. I believe that a solution to these problems is for general practitioners to develop skills in making both a diagnosis and a formulation. While a diagnosis is made on the basis of features that the individual shares with others who have similar problems, the formulation also includes features specific to that individual. It brings together all of the salient factors in the persons history that have a bearing on the development and continuation of the problem. While the diagnosis is a useful guide to treatment, the formulation allows treatment to be tailored to the specific needs of the individual. The book begins with an overview of mental health care in general practice and of the relationship between general practitioners and district mental health services. In Chapters 2 to 13, I discuss some principles of psychiatric assessment and treatment. Since much of the material in the rest of the book assumes an understanding of issues covered here, I recommend reading these chapters first. In the following eleven chapters, I describe the treatment of specific disorders. Chapter 25 deals with the issue of doctors own mental health. The final chapter was written by consumers and carers of the Logan-Beaudesert Mental Health Service as a letter to general practitioners. John Davies BMBS, FRANZCP, B.Mus (Hons) Director, Division of Mental Health Services, Logan-Beaudesert Health Service District Senior Lecturer, Department of Psychiatry, University of Queensland
xiii
Chapter 1
Working with district mental health services
Mental disorders are prevalent in the community. They produce high levels of disability and handicap and place a large burden on society. While specialist mental health services will never be able to meet the demand for treatment on their own, general practitioners are well placed to provide mental health care to the majority of those suffering a mental disorder. Indeed, most people who seek help for their mental health problems do so from their general practitioner. General practitioners will be assisted in this task through close collaboration with specialist mental health services.
problems are depression and anxiety, most often occurring together and frequently presenting with physical symptoms.While these conditions often do not present with florid symptoms, they are associated with high levels of disability and handicap. One study found that, of a group of chronic physical illnesses, only ischaemic heart disease produced levels of disability comparable with depression1. The National Survey of Mental Health and Well Being confirmed the high levels of disability associated with these disorders. Because of their high prevalence, the overall burden of these disorders is substantial. The assessment and treatment of people with mental health problems in general practice presents a number of difficulties. Since the system of Medicare rebates favours short consultations, it is often difficult to find the time to perform thorough assessments or any sort of psychotherapy. People often present their mental health problems with physical rather than psychological symptoms. In many cases, both mental and physical disorders are present. The cause of patients problems is often a complex combination of biological, psychological and social factors. The conditions seen in general practice often do not fit neatly into established diagnostic categories, and the effectiveness of drugs in their treatment is not always known. General practitioners may also have difficulties working with their local mental health service. They may be unaware of referral procedures and of the way that the mental health service functions. They may be reluctant to refer patients because of concerns that the specialist service will take over primary care of their mental health problems. They may feel that mental health services have little to offer in the treatment of people with some of their most challenging problems, such as heartsink patients or those with personality disorders. Hospital staff may not involve general practitioners sufficiently in discharge planning. Discharge summaries, if they are sent, may arrive late and not readily provide the information that the general practitioner needs to know. Mental health staff may be reluctant to discharge patients whom they know well and whose conditions are stable because of the work involved in arranging discharge and then getting to know a new patient. They may be unfamiliar with the way general practitioners run their practices and uncertain of their willingness to accept referrals for continuing care.
consult GP 76%
Wells KB, Stewart A, Hays RD et al. The functioning and well-being of depressed patients: results from the medical outcomes study. Journal of the American Medical Association 1989; 262: 914-919.
2 Working with district mental health services
Target population
The priority for district mental health services is to provide mental health care to people living in their catchment area who suffer serious mental disorders and other serious mental health problems.The target population includes people with psychotic and severe neurotic disorders, for example, those with schizophrenia, delusional disorder, bipolar mood disorder, major depression and severe obsessivecompulsive disorder. However, the seriousness of a disorder often has more to do with the level of disability and handicap than with the diagnosis or level of impairment. For example, a person with panic disorder and agoraphobia may suffer more disability and handicap than someone with schizophrenia. It should be noted that district mental health services are not funded to provide treatment to people whose primary problem is substance abuse, a marital or legal problem, or intellectual disability.
The target population for district mental health services includes people with serious mental disorders and other serious mental health problems.
General practitioners should get to know the private psychiatrists in their area, and their billing practices. You may wish to refer a person to a private psychologist for counselling, cognitive behavioural or behavioural treatments. Updated lists of local rehabilitation and disability support agencies, counselling services and relevant non-government organisations should be available from your local district mental health service or division of general practice. The following section describes the way the Logan Beaudesert Mental Health Service functions. While most services in Australia operate along similar lines, you will need to get to know how your local service operates.
Referral procedures
Within office hours, you should direct referrals to the community mental health service. Most district mental health services no longer accept outside referrals to hospital outpatients.You can make the referral over the phone or by writing a short note. An intake officer, a psychiatric nurse or allied health professional who has been trained in mental health assessment, will accept the referral. Since it is not a medical officer who performs the first assessment, the referral letter should be addressed to the intake officer, not the doctor.
Referral letters to district mental health services should be addressed to the intake officer.
All referrals are discussed the following weekday in a multi-disciplinary staff meeting when the final decision about the persons treatment plan is made. If the service accepts the person for ongoing treatment, he or she is assigned a medical officer (psychiatrist or psychiatric registrar)
A Manual of Mental Health Care in General Practice 3
and, usually, a case-manager. People needing urgent assessment out-of-hours are generally seen in the hospital emergency department. However, most services have some form of extended hours service (see below).
Recent developments
The mobile intensive treatment team Over the past five years, a number of services have been evaluating the role of mobile intensive treatment teams. These comprise a specialised group of staff who provide intensive case management to a small group of the most disabled consumers. Caseloads are kept small in order to permit high levels of care.The evaluation of this mode of service delivery has presented some methodological difficulties, but preliminary results suggest that mobile intensive treatment teams reduce hospital bed-days, produce high levels of consumer and carer satisfaction, and lead to better patient outcomes in terms of reduced impairment, disability and handicap. The extended hours service The National Standards for Mental Health Services include the provision of services 24-hours a day. Most services throughout Australia now have at least some limited after-hours capacity. For example, the Logan-Beaudesert Mental Health Service has an extended hours service that provides assessment and ongoing case management between 5pm and 9pm on weekday evenings, and between 10am and 6pm on weekends and public holidays. At other times, a phone advisory service is provided and assessments are available through the Logan Hospital Emergency Department. Community Assessment and Treatment teams In some states, Community Assessment and Treatment (CAT) teams have been established that provide assessments, intensive treatment and support, often in the persons home. In some services they act as gatekeepers to the inpatient units and also have access to alternatives to hospital accommodation such as motels or home care.
and treat the large number of their patients who suffer mental health problems. In March 1999, three million dollars was set aside from the budget of the Second National Mental Health Plan for a national initiative in primary mental health care, the aims of which are to provide education and support to general practitioners in mental health care, and to promote partnerships between general practitioners and public and private mental health services. Some of the strategies used to meet these goals include the development of educational packages on the treatment of the sorts of mental illness commonly seen by general practitioners, and programs aimed at familiarising general practitioners with the way mental health services function. A number of models of cooperation between general practitioners and mental health services have been developed. The essential prerequisite is effective communicationbetween generalist and specialist, private and public systems, and between medical and non-medical practitioners. The divisions of general practice are ideally placed to coordinate these partnerships with district mental health services*. Since November 1999 new Medicare Schedule items have been available for general practitioners to bill for care planning and case conferencing with other health professionals, without the patient being present. Items are available for the preparation and review of care plans for patients who have one or more chronic conditions with complex multidisciplinary care needs. The plan may be made on discharge from an inpatient facility or during community care. It requires informed consent from the patient. It must be documented and include jointly formulated management goals that the patient and carer agree to. It must involve the general practitioner together with two other health care providers from different clinical disciplines who are involved in the persons ongoing care and agree to work with the general practitioner to achieve the set goals. Additional items are available for case conferences. These also require the involvement of at least two other health care providers involved in the ongoing care of a person with one or more chronic conditions and complex multidisciplinary care needs. Documentation includes a list of participants, times, problems, goals, strategies discussed and a summary of outcomes. Prior consent must be obtained. The patient and the other health care providers are given a copy of the summary. The Better outcomes in mental health care initiative announced in the 2001 Commonwealth Budget has five major components: incentive payments for general practitioners to provide assessment, care planning and review of people with mental health problems; education and training of general practitioners; new Medicare Benefits Schedule items for focused psychological strategies provided by appropriately trained general practitioners; access to allied health services through funds held by divisions of general practice; and improved access to psychiatrists through a new Medicare Benefit Schedule item for psychiatrist case conferencing involving the general practitioner, a psychiatrist and one other professional with or without the patient, and provision for consultation between the general practitioner and a psychiatrist in emergency situations. The beyondblue initiative is a $35 million commitment over five years from state, territory and federal governments, lead by Victoria and the Commonwealth, to optimise the care of people with depression and related disorders1. The five priority areas are the promotion of community awareness and literacy, consumer and carer input, prevention and early intervention, applied research, and primary care training and support. The latter includes projects to improve the delivery and quality care for depression in general practice.
Information about the primary mental health care initiative in Australia can be accessed from the project officer of the Primary Mental Health Care Australian Resource Centre (PARC) at parc@ flinders.edu.au.
*
An example of collaboration between general practitioners and a district mental health service
The Logan Area Division of General Practice provides support to general practitioners working in an area situated about halfway between Brisbane and the Gold Coast. The Logan Beaudesert Mental Health Service provides mental health care to residents in the Logan Beaudesert Health District, which includes the area covered by the Division, but also extends south, around the western boundary of the Gold Coast District, to the New South Wales border. The Division and the Service have collaborated on a number of projects over the past six years. The case-conferencing project comprises eight two-hour sessions in which general practitioners meet with two psychiatrists from the Service. In the first hour, there is discussion on a focus topic taken from this book. In the second hour, a psychiatrist interviews a patient of one of the general practitioners in front of the group. A discussion of issues raised by the case then follows. The project has succeeded in increasing general practitioners knowledge of the sorts of mental health problems that they commonly see and their familiarity with the Service1.
The case-conferencing project and the SPHERE program aim to improve the skills of general practitioners in treating the mental health problems that they commonly see.
General practitioners in the Division have also undergone training in the SPHERE program, which takes its name from the Somatic and Psychological Health Report (SPHERE), a selfreport instrument developed for the detection of psychological problems in general practice populations2. The program comprises four components: a case-identification system for psychological disorders; a four-seminar training program for the management of depression and anxiety by general practitioners; a 12-month disease management program for use by general practitioners; and ongoing doctor support through the provision of clinical and educational materials and further educational activities. More extended programs are being developed to cover cognitive behavioural therapy, chronic fatigue and chronic pain, geriatric depression and adolescent mental health problems. The Logan Area Division of General Practice has recently been chosen to be one of the metropolitan sites for the General Practice and Psychiatrists Partnership program (GPAPP), an initiative coordinated by the Queensland Divisions of General Practice (QDGP) and funded by the National Mental Health Strategy through Queensland Health. It is based on the Consultation-Liaison in Primary Care Psychiatry Project (CLIPP), which was pioneered in Melbourne3. Psychiatrists from the District Mental Health Service visit group practices once a fortnight to provide on-site consultation on the management of difficult cases. In Melbourne, the project has facilitated the transfer of patients care from district mental health services back to primary care.
Davies J, Ward W, Groom G, Wild A, Wild S. The case-conferencing project: a first step towards shared care between general practitioners and a mental health service. Australian and New Zealand Journal of Psychiatry 1997; 31: 751-755. 2 Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T and Naismith S, Koschera A. The SPHERE Program: A training manual for treating depression and anxiety in general practice. Kogarah: Educational Health Solutions, 1998. 3 Meadows GN. Establishing a collaborative service model for primary mental health care. Medical Journal of Australia 1998; 168: 162-165.
1
The metropolitan pilot of the GPAPP program aims to provide on-site consultations to general practitioners on the treatment of people with mental disorders.
Over the past year, the Division and the Service have collaborated on the shared care project. This involves a case manager from the Service working with a group of general practitioners who have completed the case-conferencing project in the management of around twenty people with schizophrenia. The general practitioners meet with a psychiatrist once a month to review patient care and for ongoing education. Preliminary results show high levels of satisfaction amongst all participants. There were no significant changes in mental health outcome, though an unexpected result was a reduction in occupied bed days in hospital. A number of physical disorders were diagnosed and treated.The project has subsequently been extended to include 20 general practitioners in the Division and all case managers of the Service. These projects constitute changes in the culture of mental health service delivery towards greater cooperation between public and private sectors and specifically between mental health services and general practitioners. The aims are improved patient outcomes, more efficient service delivery and a lessening of psychiatric morbidity in the community.
The aim of educational and shared care projects is to improve health outcomes in the population by changing the culture of mental health care delivery towards greater cooperation between the public and private sectors.
Chapter 2
Mental health assessments
This chapter begins with a discussion of eight principles of the psychiatric interview. An outline of the psychiatric history and mental state examination follows. In the final section, I discuss the differences between a diagnosis and a formulation and provide several sample formulations.
The use of self-report questionnaires, such as the SPHERE-GP, can save time in the consultation. 2. Reassurance
As a rule, it is better to try to understand a persons experience more clearly than to give bland reassurance. Although you may mean well, he or she may perceive a reassuring comment as presumptuous or rejecting. However, reassurance does have a place when it is true and does not dismiss the persons experience. It may then instil hope. Some examples are given in Box 2-1.
Helpful comment:
(To a depressed man) When people are depressed, they often feel that nothing can be done to help. There are effective treatments for depression and I know that I can help you.
3. Interview technique
The following characteristics of interview style improve the likelihood of detecting mental illness:
Goldberg DP, Williams P. A Users Guide to the General Health Questionnaire Windsor: NFER-Nelson 1988. 2 Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T and Naismith S, Koschera A. The SPHERE Program: A training manual for treating depression and anxiety in general practice. Kogarah: Education Health Solutions, 1998.
1
listening, clarifying and asking for an example not interrupting, especially at the beginning of the interview asking open-ended questions, especially at the beginning of the interview asking directive psychological questions an empathic style This involves putting yourself in the other persons position so as to understand how he or she feels, thinks and behaves, and why he or she feels that way. However, empathy is not simply an uncritical acceptance of a persons ideas and impulses (see the note on pseudoempathy in Box 12-3). picking up and responding to verbal and non-verbal cues maintaining control of the interview. Examples are given in Box 2-2.
Empathic style
A middle-aged man becomes depressed after being overlooked for a promotion at work.You ask about his prospects for promotion in the future. This uncovers his fear that, at 52, he is unlikely ever to be promoted. The question that you ask leads the man to elaborate his concerns. Further questions may address the other developmental challenges of middle age that he is presently facing.
Maintaining control
An elderly man speaks at length about how unjustly he is treated by his neighbours.You say, I am sorry to hear that you are so upset by your neighbours, but could I take you back to what you were saying about feeling depressed.
10 Mental health assessments
feelings are reality-based, for example, respect for your expertise in medicine. Others have unconscious origins and arise from the transference on to you of feelings that are held towards others who are significant in the persons past or present. For example, being perceived by a young man as an authority figure, you may elicit transference feelings that he has towards his parents, teachers and other authority figures in his life. Countertransference refers to the feelings that you have towards the patient. Again, these will, in part, be reality-based. Some will arise in response to the transference. Some will be similar to feelings that are elicited in other people who deal with that person, while others will reflect aspects of your own past and present relationships transferred on to the patient. Most will be a combination of all of these. It is normal, of course, that you should experience these feelings. The important thing is to be aware of them and to acknowledge them to yourself, even if they seem unacceptablefor example, feeling angry or bored with a person, feeling overly concerned about or even feeling attracted to him or her. By acknowledging these feelings to yourself and making them conscious you are much less likely to act inappropriately upon them. For example, it is quite normal to feel angry with certain people, but it is likely to be damaging and unprofessional to act out this anger.
By acknowledging to yourself your countertransference responses, you lessen the likelihood of acting out upon them.
Monitoring your countertransference responses can provide you with valuable information about a person. For example, when seeing a young woman who repeatedly self-harms, you may feel frustrated and angry and you may even imagine being cruel to her. Recognising these feelings and impulses, you take care not to act out upon them. Reflecting upon them, you recognise their origin in the physical and sexual abuse that she suffered at the hands of her foster father.You gain a deeper understanding of her and the way people react towards her. By containing the impulse to act out, you avoid repeating and reinforcing the abusive patterns of her previous relationships. At the same time, you take care not to act upon unrealistic fantasies of rescuing her (see also Chapter 22).
Monitoring the countertransference can improve your understanding of the patient. 5. Boundary issues
Doctors are sanctioned to ask about private and intimate aspects of their patients lives and to conduct physical examinations. There is a clear power differential in the relationship between patient and doctor. In particular, people presenting for counselling or any type of psychological therapy are often at their most vulnerable. The transference of flattering feelings and impulses onto the doctorrespect for authority, attraction to power and success, desire for approval may tempt the doctor into abusing his or her power.To exploit such a position to fulfil ones own needs is unethical and potentially damaging to patients. It is essential to be clear about your role as a professional. You are not a friend of the patient. Indeed, it is wise to avoid, if possible, treating your friends. It is always unethical to have sexual relations with a patient. For professional therapists, it is prohibited to have intimate relations even after therapy has finished. Monitor your countertransference feelings and impulses and take care not to act out in ways that breach professional boundaries. Transgressions of these boundaries typically occur in a stepwise progression. They may begin with the acceptance of expensive gifts, financial or stockbroking advice, or even betting tips. There may be a temptation to disclose and discuss ones own problems. Appointments may be made that are longer than usual, or regularly scheduled
A Manual of Mental Health Care in General Practice 11
at the end of the day when other staff members have left the practice. Fees may be waived. Unnecessary home visits may be made. This may progress to the performance of unnecessary physical examinations, meeting patients outside the consulting room, and to involvement in social situations and sexual relations. Doctors who are vulnerable to boundary transgressions include those experiencing life crises, in particular those with problems in their own marriages or personal relationships1. Perfectionists who are excessively self-sacrificing and work unnecessarily long hours may have difficulty setting limits on the demands of certain patients and begin taking extraordinary measures in attempt to rescue them. Patients with histories of sexual abuse may be particularly prone to evoke such countertransference responses, especially when they express recurrent suicidal ideation. Doctors who deny their dependency needs and give the appearance of being self-contained may be prone to seeking gratification for their needs for love and nurturance through their patients: while denying their own dependency needs, they may perceive others as being dependent on and needy of them. A doctor suffering a psychosis might violate professional boundaries as a consquence of the illness. Psychopathic doctors who wilfully exploit patients for the gratification of their own needs have no place in the medical profession.
We can understand the grief of the bereaved, the anger of someone who has been frustrated, the guilt of the person who has hurt someone else, and the shame of someone who has done something foolish.
By contrast, aspects of some mental states are not understandable in this way. For example, there is no understandable reason for the memory loss of someone with dementia. We cannot empathise with changes in another persons brain. Instead, we seek an explanation in terms of a causein this case, a disruption in brain physiology and a loss of brain substance. Similarly, we cannot understand how a person with schizophrenia starts hearing voices.There is no meaningful reason for this reaction and we cannot empathise with it. Instead, we seek explanations in terms of neurotransmitters, abnormalities in information processing and other physical causes.
Gabbard GO. Psychodynamic approaches to physician sexual misconduct in Physician Sexual Misconduct, Eds Bloom JD, Nadelson CC, Notman MT. Washington DC, American Psychiatric Press, 205-223.
1
12
The memory loss of someone with dementia or the hallucinations of someone with schizophrenia are not understandable. There is no reason for them. Instead, they require an explanationa cause.
An understandable reaction is not necessarily a normal one. For example, you might understand why a high-achieving man becomes depressed following a myocardial infarction. However, this should not stop you from diagnosing major depression if his depressed mood persists and he expresses feelings of worthlessness and guilt, and suicidal ideation. While the understandable aspects of a condition may be amenable to some form of psychotherapy, the condition may also require some pharmacological intervention or even ECT.
Although a problem may be understandable, its treatment may require pharmacological or other physical interventions.
Since all mental disorder is both a disorder of mind and of the brain, it is always possible to both understand and explain different aspects of the same problem. The grief of a bereaved woman will be reflected in biochemical and other events in her brain. However, the fact that her reaction is clearly understandable indicates that our initial treatment would be through grief counselling. If her grief is prolonged, and she begins to suffer prominent and distressing feelings of guilt, and is contemplating suicide, we would use an anti-depressant drug as an adjunct to the grief work. Similarly, in the case of a man with schizophrenia, although we may not be able to understand the evolution of his auditory hallucinations (the form of his experience), we may be able to empathise with their content. We can also empathise with his reactions to the disability and handicap that he suffers as a consequence of the illness. For the person with dementia, the feelings of loss, fears about the future, and the change to a more dependent role are all issues that are understandable and amenable to psychotherapy and counselling.
While the form of a delusion proper is not understandable, it is often possible to empathise with its content. 7. The dialectical principle
In the philosophy of Hegel, dialectics is a process in which a proposition is made (thesis), then negated (antithesis), and finally replaced by a new proposition that resolves the conflict between the two (synthesis)1. Although this may seem a little obscure, this way of thinking is common in making decisions about mental health problems. You will often have to make choices between apparently contradictory propositions. Always consider the possibility that the best course of action lies in a synthesis of the two. There are very few propositions in psychiatry that hold true in every case. Some examples of these dialectical dilemmas are given in Box 2-3.
In psychiatry, the best solution to a problem is often a synthesis of two apparently contradictory possibilities. 8. Impairment, disability and handicap
When assessing people with mental health problems, it is useful to classify their complaints as impairments, disabilities or handicaps. Mental impairment is any loss or abnormality in psychological functioning. It includes the signs and symptoms of mental illness. Disability is any restriction or lack in ability to perform an activity normal for a human being. Handicap is a disadvantage, resulting from impairment or disability, that limits or prevents the fulfilment of a
1
Brown L, Ed. The New Shorter Oxford English Dictionary. Oxford: Clarendon Press, 1993.
A Manual of Mental Health Care in General Practice 13
social role that is normal for that individual, given his or her age, sex and cultural expectations. It is helpful to make this distinction when planning management. In general, the alleviation of impairments is the focus of treatment, while the prevention and minimisation of disabilities and handicaps constitutes disability support and rehabilitation. As a general practitioner, you will mainly be involved in the delivery of treatment. However, you need to be familiar with the rehabilitation services in your area, to know the appropriate referral procedures and to be able to work in partnership with them. Some examples of impairment, disability and handicap are shown in Box 2-4.
14
General practitioners treat patients impairments and coordinate their rehabilitation to minimise disability and handicap. Box 2-4: Examples of impairment, disability and handicap
A woman with schizophrenia hears her thoughts spoken out loud (thought broadcast, an impairment). As a consequence, she withdraws, spending much of her time at home, and she no longer goes shopping (agoraphobia, a disability). She has not managed to work since the onset of her illness five years before, she has no social contacts outside her immediate family and she depends on her husband to do all of her shopping (handicap). A man has developed agoraphobia (disability) after having a panic attack (impairment) in a bank three months before. He remains on sickness allowance and sees little of his friends. His wife is becoming increasingly exasperated by his dependence on her (handicap). A man with early dementia suffers memory deficits, disorientation in place and mild agnosia (impairments). He has left the gas on twice after heating the kettle, he got lost on the way back from the shops and his wife has to remind him to attend to his personal hygiene (disabilities). He had to give up his job as an architect a year ago and is now becoming increasingly dependent on his wife for care and supervision (handicap).
The presenting complaint and mental state examination are the most important parts of the psychiatric assessment.
Hadzi-Pavlovic D, Hickie I, Ricci C. Somatic and Psychological Health Report: development and initial evaluation. Technical Report TR-97-002, School of Psychiatry, University of New South Wales, Academic Department of Psychiatry, the St George Hospital and Community Health Service, 1997.
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Psychiatric history
Identification data
Most of the persons identification data is probably obtained when he or she registers to see you. As well as name, age and address, it is also useful to know whom patients live with, the type of accommodation they occupy, their occupational status and their means of support. In discussing a patient with a colleague, it is useful to state these facts at the outset.
names of previous therapists past admissions number, length, place and treatment, especially the first and the most recent admission.
Current medication
Record drug names and doses for both physical and mental illnesses. Are there any that might be affecting the persons mental state? Are there potential interactions with the drugs used to treat the mental disorder?
Forensic history
Note any serious offences, especially those leading to imprisonment. Is there a history of violence towards others? Is the person facing any current charges?
Ask if you can speak to the persons spouse, family or other carers in order to gain collateral information and to involve them in treatment.
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Personal history
As the persons general practitioner, you may already know much of his or her personal history: circumstances of birth developmental milestones relationship with parents and siblings schooling childhood neglect, abuse or trauma work history marital/relationship history current interests. Schooling, work history and the quality of a persons relationships are important guides to the stability of his or her personality. For example, the fact that a woman has been happily married for 15 years and has been content and settled in the same job for the past 10 years suggests that she has a strong and stable personality. These are important protecting factors that indicate a good prognosis. The precipitants of current problems may have significance in terms of a persons developmental history Box 2-6.
Pre-morbid personality
A persons pre-morbid personality may predispose to the development of mental disorder. For example, a person with dependent traits may be vulnerable to depression following a separation. Be careful not to confuse a persons current mental state with his or her normal way of behaving. For example, during a manic episode, a man may appear histrionic, but this may be quite unlike his normal personality.
Schooling, work history and the pattern of a persons relationships are important guides to the stability of his or her personality.
See Chapter 12 for a discussion of the following core psychodynamic issues. Their assessment will often enhance the formulation. 1. impulse control 2. self-esteem 3. shame and guilt 4. quality of relationships 5. defence mechanisms 6. developmental challenges
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d) Thought stream A person with mania may exhibit flight of ideas. Someone with depression may be psychomotor retarded. The thinking of people with organic disorders or certain personality disorders may be circumstantial.
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Cognition In an acute brain syndrome (delirium) the onset is usually rapid, and the level of consciousness, orientation, concentration and attention span, as well as memory and other areas of cognitive function are impaired. Delirium frequently presents with a variety of other abnormalities on the mental state examination, including perceptual abnormalities (e.g. hallucinations and illusions) and delusions.
A rapid onset of symptoms that include an altered level of consciousness, disorientation, and impaired attention and concentration suggests a diagnosis of delirium.
People with chronic brain syndromes, such as dementia, usually suffer an insidious onset of the illness. They are usually alert, (i.e. have a normal level of consciousness) and sometimes oriented with normal attention, but have deficits in memory, especially short-term memory, and in other areas of cognitive functionabstraction, judgment, and higher cortical functioning. They may also undergo a change in personality (see Chapter 17). People with severe functional disorders, such as major depression, may exhibit pseudodementia that is, despite having normal cognitive capacity, they perform poorly on tests of cognitive function because of the severity of their mental disorder. The principal components of the assessment of cognitive function are listed below. A useful screening test is the mini-mental status examination (see Appendix 2). a) Level of consciousness This ranges from alert through clouded to comatose. b) Orientation Test orientation in person, place and time. c) Attention This may be tested using serial 7s, serial 3s, by spelling world backwards or by asking the person to recite the months of the year backwards. d) Memory Any person with dementia will have some degree of amnesia. Confabulation is a feature of Korsakoff s psychosis, but can occur in any disorder in which memory is impaired. Test immediate recall by asking the person to repeat a name and address or three objects. Short-term memory can be tested by recall of the name and address (or the objects) after five minutes.You can usually test long-term memory during the clinical interview.You can test it formally by asking questions about past world events. e) Other tests General knowledge can be tested by asking about current world events. Remember to take into account a persons education and cultural background when selecting suitable questions. Tests of abstract thinking include asking the person the interpretation of a proverb, or asking differences (e.g. between ice and glass, or between a dwarf and a child). Judgementthe ability of a person to make rational plans of actionis usually assessed while taking the history, but can be tested formally by asking what the person would do if she or he found a stamped, addressed envelope. f) Intelligence The assessment of a persons current functioning in the light of his or her educational and occupational background is required in the diagnosis of dementia. Neuropsychological assessment provides more detailed information. A high IQ is sometimes a protecting factor for someone with a mental disorder, but on the other hand, intelligent people may be acutely aware of losses they suffer as a consequence of illness.
Insight Insight refers to the ability of a person to understand his or her problems, their
origin and what can be done to overcome them. It is rarely an all-or-none phenomenon. For example, a man with schizophrenia may deny that he has the illness and still believe in the reality of his delusions, yet at the same time regularly attend appointments and adhere to prescribed medication. What is important for the person to understand depends on the condition from which he or she suffers and the treatments available. For a person with a psychotic illness, an
20 Mental health assessments
acceptance of the need for treatment and monitoring is often the most critical issue. By contrast, a man with personality disorder needs to understand how certain of his habitual ways of dealing with other people and with life events cause him and others distress. For a man undergoing a course of behaviour therapy, understanding the origin of his problems is less important than having the motivation to change and persist with therapy. In psychodynamic psychotherapy, the emphasis is on understanding ones habitual ego defences and ways of responding that have led to problems in the past. Change occurs through the repeated working through of solutions that have lead to maladaptive responses in the past in order to learn and consolidate new responses.
Both a formulation and a diagnosis are required in the comprehensive assessment of a person suffering mental health problems. Table 2-1: Differences between a diagnosis and a formulation
Diagnosis Nomothetic (i.e. assigns individuals to groups with shared characteristics) Validity tested using scientific methods Formulation Ideographic (i.e. focuses on the uniqueness and complexity of the individual) Validity judged on the basis of the reliability and salience of the data used and the plausibility of the interpretations made Narrative that answers the question, Why is this individual suffering these problems at this time? Seeks reasons for a persons problems (i.e. an understanding of it)
Summary label, for example, depression or schizophrenia Precedes search for causes of disorders (i.e. an explanation for it)
Formulation
The different factors that make up a formulation are shown in Table 2-2. Biological factors Any physical disorder that directly or indirectly affects the central nervous system can influence a persons mental state. Similarly, drugs and other substances that gain access to the brain, or that indirectly affect brain function, can cause mental symptoms. Mental symptoms commonly arise as a psychological response to having a physical disorder. Genetic factors contribute to the development of the psychoses, but also to disorders such as personality disorders and substance abuse.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Association, 1994. 2 World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. Geneva: World Health Organisation, 1992.
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Psychological factors A persons personality, its strengths and vulnerabilities, can either predispose to mental illness or protect against it.The 10 personality disorders described in the DSM-IV are discussed in Chapter 23. The psychodynamic assessment of personality covers patients characteristic defences, their ability to control impulses, their ability to maintain self-esteem, the quality of their relationships, and their capacity for shame and guilt (see Chapter 12). Mental disorders are often precipitated by stress. The stressor may be an adverse event such as a loss or a desirable one such as marriage. It could be a normal developmental challenge, for example, an adolescent leaving home or a 65-year-old facing retirement. In general practice populations, mental disorders commonly occur as a psychological response to having a physical disorder. The stressor may have special significance for that individual in terms of his or her history: for example, a relationship breakdown would be particularly stressful to a woman who lost her parents during her childhood. Social factors Strong social supports are protective against mental illness and ensure a better prognosis. Limited social support is a vulnerability. Stressful patterns of social interaction tend to perpetuate mental illness. For example, a high level of expressed emotion (hostility, critical comments and enmeshment) increases relapse rates in schizophrenia and depression. Unemployment is associated with increased levels of both mental and physical morbidity. A persons ethnic and cultural background may predispose to the development of mental disorder and influence the way in which symptoms are presented (see Chapter 4).
The following vignettes illustrate the different factors that make up a formulation.The numbers refer to the boxes in Table 2-2. Most of these examples are best regarded as partial formulations because they do not attempt to bring together all of the elements in a persons history. However, to avoid artificiality, some include more than the just the factor being illustrated. 1. Both parents of a 45-year-old man with schizophrenia were treated for the same condition. Comment: He had a biological (genetic) predisposition to the development of schizophrenia. With both parents suffering the condition, his lifetime risk at birth was around 45 per cent. Note, however, that his identical twin brother, who has never suffered psychotic symptoms, now has only a small risk of developing the illness because the onset almost always occurs before the age of 40. 2a. A 60-year-old man who is alcohol dependent develops alcohol withdrawal delirium three days after admission to hospital for repair of a fractured neck of femur. Comment: The precipitant is the withdrawal from alcohol in a man who is alcohol dependent. Other factors, including post-operative complications, could also be playing a part. 2b. A 65-year-old woman is admitted to a psychiatric ward with a diagnosis of depression. In addition to her low mood, she describes loss of appetite, a threekilogram weight loss over the past two months and a loss of energy. She is convinced she has cancer. On physical examination, she looks unwell. Her skin is sallow and
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she appears jaundiced. Subsequent investigation reveals carcinoma of the pancreas. Comment: Depression is commonly associated with a number of medical conditions, including carcinoma of the pancreas, Parkinsons disease, Huntingtons disease, stroke, hypo- and hyper-thyroidism, hypo- and hyper-parathyroidism, SLE, hepatitis, infectious mononucleosis and HIV. It is always important to consider an underlying physical illness as the cause of psychiatric symptoms. Physical illnesses remain at the top of the diagnostic hierarchy.There is always the danger of coming up with a plausible psychosocial formulation for symptoms and missing the underlying physical condition. 3. A young man with schizophrenia is admitted to hospital with an exacerbation of his psychotic symptoms (derogatory voices, delusions that he is being chased). He has been smoking marijuana every day over the past three weeks and he has used intravenous amphetamines three times over the past week. Comment: The marijuana and amphetamines are likely to have precipitated his relapse. His continued use will perpetuate the illness. 4. A 70-year-old widower is treated for an episode of major depression. Since his wifes death two years before, he has become socially isolated.As part of his rehabilitation, he is encouraged to join a local bowls club. He also begins working as a volunteer for Meals on Wheels. Comment: This vignette is given as an example of a biological protecting factor. His good physical health enables him to play bowls and to participate actively in delivering Meals on Wheels. 5. A 50-year-old violinist with the Queensland Symphony Orchestra presents with anxiety, depression and agoraphobia. She has been unable to return to work since suffering an epileptic seizure four months ago while on stage in the Performing Arts Complex. Thorough neurological investigation has failed to reveal any abnormality. The precipitant appears to have been fatigue coupled with withdrawal from benzodiazepines. She is described pre-morbidly as being a perfectionistic, conscientious, hardworking, and strong-minded person who is a capable and willing organiser. Comment: Pre-morbidly, she demonstrates a number of obsessivecompulsive personality traits (see Chapter 23). An important dynamic in people with these traits is the need to feel in control. Her epileptic seizure, which occurred in public and involved incontinence, represents an extreme loss of control for her. The blow to her self-esteem has resulted in depressive symptoms. The fear of having another fit has lead to avoidance and agoraphobia. 6. and 7. A 50-year-old woman is brought to see you by her daughter. She has been unable to leave the house unless accompanied by her daughter or her husband since having a panic attack two months ago in the entrance to the Logan Plaza shopping centre. Her daughter has been doing all the shopping recently and has been taking meals to her parents every evening. She is beginning to feel tired and exasperated by the situation. The patients husband is reportedly less concerned and, in fact, feels that his daughter is exaggerating the problems. He has refused to see you. He works as a taxi driver and has over recent years become suspicious that his wife is having an affair. Not a day goes by when he does not interrogate her and he frequently drops home to check up on her during the day. Comment: Her fear of having another panic attack has led to avoidance behaviour (agoraphobia). This is reinforced by her husbands suspiciousness and intimidation, and also by the secondary gains of bringing her daughter closer and of being cared for by her. 8. A man with paranoid schizophrenia is an excellent chess player. Although unemployed, he attends a chess club three times a week where he continues to perform well. Comment: Although he suffers from schizophrenia, he is an intelligent man who is gifted at chess. Playing and studying the game is largely a solitary occupation that presents few threats to him. Indeed, the determination and single-mindedness that are features of his game
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reflect a positive side of his paranoia. 9. A 13-year-old girl suffers from anorexia nervosa. Her father is an advertising executive whose work often takes him interstate or overseas. He and his wife often entertain business associates at homeshe has a reputation as an excellent cook. She herself has struggled with her weight over the years and is currently attending a weight loss centre. The girl attends a private girls school where she is described as a good student who is always well behaved. She also studies ballet. She has been on diets before, sometimes together with a school friend, but these have never lasted longer than a few weeks. She has been dieting now for three months. Her mother remembers her being upset at a family barbecue around the time of onset when her paternal grandmother commented that she was looking fat. Comment: The vignette is given to illustrate how social factors can predispose to the development of mental illness. Certain societal forces, derived especially from advertising and the popular press, dictate that women should be thin. This view is particularly prevalent in the worlds of gymnastics, ballet, modelling and athletics. The complete formulation would also include a number of other factors. Her mothers preoccupation with dieting suggests a possible genetic and/or learned component. Food often plays an important role in communication within the families of anorexics. Such families may exhibit an orientation towards success that limits the free expression of feelings, the respect for each individuals autonomy and the resolution of conflict. The precipitant appears to have been the critical remark made by her grandmother. Pre-morbidly, she had several obsessivecompulsive personality traits (perfectionism and conscientiousness).The anorexic symptoms can be seen as an attempt by a girl with a fragile self-esteem to gain control at a time when she is undergoing the physical and social role changes of adolescence. Moreover, the dieting itself will interrupt her physical, social and cognitive development. 10. A 60-year-old widow presents with major depression.The precipitant was the anniversary of the death of her husband a year ago. She had an ambivalent relationship with him. He was an alcoholic and was both verbally and physically aggressive towards her and her children, especially when he was intoxicated.A number of people commented on how well she seemed to cope after the funeral. She had not cried and was soon back engaged in her usual activities. Her father too was a violent manthe patients mother left him, taking the three children with her when she was eight years old.The family had no subsequent contact with him.They were notified five years later that he had died in a motor vehicle accident some months before. Comment: Her depression has been precipitated by the anniversary of the death of her husband, a man towards whom she has ambivalent feelings. On one hand, she is angry because of the years of abuse she and her children suffered at his hands, and now, because of his abandonment of her. She also feels guilty because she had often wished him dead. On the other hand, she remains sad at the loss of her marital partner. The loss also rekindles unresolved issues over the loss of her father. Grief counselling will aim to help her acknowledge, experience and work through these ambivalent feelings. 11. A young man with schizophrenia is admitted to hospital with his third exacerbation of psychosis in the past six months. His mother describes considerable conflict at home. The father has never been able to accept his illness, sees him as lazy and frequently criticises him for not going out and getting a job. There is also marital conflict, frequently over the patient. On a number of occasions, the young mans father has given his wife the ultimatum that either his son moves out of the house or he will. Several attempts have been made to accommodate the young man away from home, but his mother remains convinced that he is unable to look after himself and these attempts have generally only lasted for about two weeks. He has usually run out of money and phoned his parents. His father has driven around, collected all his belongings and taken him back home. Comment: An important perpetuating factor in his illness is the high expressed emotion (EE) at home. The three components are hostility, critical comments and enmeshment.
24 Mental health assessments
12. A 33-year-old man presents with his girlfriend of eight years and describes a 10-year history of paranoid delusions that the members of a bikie gang are chasing him. His girlfriend has managed to look after him and reassure him over this period. He has never previously sought psychiatric help. He has managed to do some casual work over the years as a painter, employed by his girlfriends brother. On this occasion, she brought him to hospital because, for the first time, he had been talking about suicide. Comment:The strong support he receives from his girlfriend is an important protecting factor. On the other hand, this support may have prevented earlier treatment and so worsened his prognosis.
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Chapter 3
Suicidality and dangerousness
Around one in every 100 deaths in Australia is by suicide. The rate among people who have had at least one admission to hospital for a depressive illness is five times that in the general population. Men complete suicide at twice the rate of women. Of particular concern over the past decade has been the alarming increase in the rate of suicide among young people, especially young men living in rural areas. The rate in this group is around 36/100,000 per year.
Assessment of suicidality
Risk factors
Population studies reveal a number of risk factors for suicide. 1. Demographic factors a) Age: In general, suicide risk increases with age. However, there is a peak for young men between the ages of 15 and 24. For older women the risk actually falls. b) Sex: Males complete suicide at rates around twice those for women. Young women are at higher risk of self-harm. c) People who are separated, divorced, widowed, single or living alone have an increased risk. Caring for a child is protective. 2. Unemployment, retirement or a fall in socio-economic status 3. Previous attempts: A history of previous attempts increases the risk of completed suicide. Be careful not to fall into the trap of thinking that because a person has repeatedly self-harmed in the past that he or she will not complete suicide in the future. The risk increases with the lethality of previous attempts. Knowing someone who has committed suicide, or having a family history of suicide, increases risk. Copycat suicides may follow media coverage of the suicide of high profile people or others with whom they identify. Previous attempts that occurred in the absence of any clear precipitant indicate high risk. 4. Physical illness: especially chronic, severe, disabling or terminal illness
Physical illness that is chronic, severe, disabling or terminal is associated with an increased risk of depression and suicide.
5. Mental disorder: especially major depression, bipolar disorder, schizophrenia, borderline and antisocial personality disorder and substance abuse. A history of impulsive behaviour increases risk. Repeated deliberate self-harm is often associated with a history of childhood abuse. 6. Symptoms: Hopelessness (the belief that things are not going to change, but stay bleak into the future), anxious ruminations, severe psychic anxiety, global insomnia, psychotic symptoms (especially delusions of poverty or doom) and recent alcohol abuse are predictors of suicide. One study has calculated that 72 per cent of those with a suicide plan go on to make a suicide attempt1.
Kessler RC, Borges G, Walters EE. Prevalence of and risk factors for lifetime suicide attempts in the National Co-morbidity Survey. Archives of General Psychiatry 1999; 56:617-626.
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Hopelessness, anxious ruminations, severe psychic anxiety, global insomnia, delusions of poverty or doom, recent alcohol abuse and having a suicide plan are associated with later suicidal behaviour.
7. Availability of means: Access to lethal means such as firearms increases risk. 8. Risk periods: early in treatment or soon after hospital discharge. A sudden unexplained improvement can be a danger sign.The person may have decided to commit suicide. Suicide attempts may occur on the anniversary of important losses.
The interview
The assessment of suicidality is summarised in Table 3-1. 1. Consider the persons risk factors (as above). 2. Ask about suicidality. Begin by asking general questions (e.g. Does it ever seem that life is not worth living?). Then proceed to more direct questions (e.g. Have you thought of harming yourself or even killing yourself?). Clarify if the person has a suicide plan, how specific it is, the lethality of means, whether it has been rehearsed and whether preparations have been made for the persons death (e.g. arranging insurance, finalising a will). There is some evidence that asking about suicide may suggest it as a possible solution to life problems, especially in adolescents who had not previously considered it as an option. Make sure that you follow up the question with a discussion about alternative strategies for solving the persons problems, and seek an agreement that if ideas of suicide recur in the future, the person will first seek help.
Ask about suicidality, but always be prepared to follow up the question with a discussion about alternative solutions to the persons problems.
3. Assess the suicidal act or intention. It is often useful to ask the person to describe what happened in the days leading up to a suicide attempt.You will then understand the context in which the attempt occurred and the meaning of the act. Was the act planned or done on impulse? Was alcohol involved? Did the person expect to die or was another outcome intended? Some people may take an overdose, for example, simply to get away from their problems and to sleep. Others may expect to be rescued. Writing a note may demonstrate a high level of intent. Assess the lethality of the act by noting the means, the situation in which it occurred and whether others were nearby. Ask about access to firearms and other means. The lethality of the act may not correlate with the intent. For example, many people are unaware of the potential fatal consequences of paracetamol overdose. Others may have truly expected a minor overdose to have been fatal.
4. Assess the meaning of the act or intention. Assess the persons reasons to die versus (his) reasons to live. Assess the meaning to (him) of suicide and death. Risk is increased when this takes on a positive meaning (e.g. identification or reunion with a loved one, or fantasies of rebirth). 5. Assess the problem. Suicidal acts are attempts at solving problems in a persons life.They often occur in response to relationship difficulties. People who self-harm may do so in the belief that they will elicit sympathy and restore threatened relationships. In reality, they more often induce guilt and anger in others, and tend to drive people away rather than bring them closer, especially when repeated suicide attempts are made. Clarifying the precipitating problem is the first step in trying to resolve it. Listening to a person describe his or her problem will itself provide some relief.You may be the first person who has taken the time to do this.Then
28 Suicidality and dangerousness
use the counselling and structured problem solving techniques described in Chapter 6 to help the person resolve the crisis.
Disorders commonly associated with suicide include depression, panic disorder, alcohol and substance abuse, and schizophrenia.
7. Is there an underlying physical disorder? People with severe physical illness, especially the elderly, have an increased risk of suicide. 8. Ask about previous suicide attempts or self-harming behaviour.The frequency and seriousness of these give an indication of current suicide risk. 9. Assess protective factors. Those with limited social supports are at high risk. On the other hand, strong social supports are protective. The ability to mobilise supports is an important factor in treatment. Assess other protective factors: guilt about the impact of suicide on the persons family (especially their children), fears of death and of the unknown, social stigma, and religious proscriptions against suicide.
Management
1. Treat the physical sequelae of the suicide attempt. You may need to refer the person to hospital for inpatient treatment. 2. Document the suicide risk assessment and the reasons for your actions. 3. Establish a therapeutic alliance. Listening to the person, being sensitive to verbal and nonverbal cues, and having an empathic style will promote open communication. Note, however,
A Manual of Mental Health Care in General Practice 29
that once a person has decided to commit suicide, you will be seen as an adversary rather than an ally. For this reason, it is important not to place too much reliance on a simple denial of suicidal intent. A majority of people who complete suicide have not mentioned their intention to their therapist, or have denied such an intention. On the other hand, people often communicate their intentions to spouses or family, a fact that underlines the importance of interviewing family members. 4. Ensure the persons safety. Before sending a (man) home, you should aim to reach an agreement that he is no longer suicidal and that if suicidal thoughts recur, he has a plan for getting help before self-harming (see Table 3-2). The plan may involve telling a family member of any suicidal thoughts, or of contacting you or the district mental health service. When he cannot give such an assurance, or when his judgement is so poor that he is not in a position to make such an agreement, it may be necessary to hospitalise him. You may need to do this under the provisions of the Mental Health Act (see Chapter 22). Note that a simple agreement not to commit suicide is of little value in itself, though a refusal to ensure ones own safety constitutes a significant risk. 5. Mobilise social supports.The safety agreement will usually require the cooperation of family members or other close supports. The precipitating problem usually involves those who are close to the person. A plan that has the agreement of everyone concerned is more likely to succeed and all participants will share some responsibility for its implementation. 6. Diagnose and treat the underlying mental disorder. In the immediate aftermath of a suicide attempt, explain the nature, causes, treatment and prognosis of the underlying condition to the person and his or her carers.This will give the person a sense of control and help restore hope. 7. Deal with your own and others emotional reactions. Suicidal behaviour evokes strong feelings in those close to patients and in those who treat them. Monitor your countertransference to ensure that these feelings do not distort your judgement. Common reactions include: denial for example, you may find yourself colluding with the person who says that an obviously serious suicide attempt was just an accident anger and distancing you may, for example, dismiss a persons suicidal thoughts as merely manipulative or attention-seeking rescue fantasies these might arise, for example, in response to a young woman who repeatedly self-harms. Despite the inability of all her previous therapists to prevent these distressing behaviours, you may be tempted to believe that you, and only you, can save her. This may lead you to denigrate her other therapists and to take extraordinary measures to save her, which may in turn lead to burnout and boundary violations. Taking desperate measures to prevent a person from self-harming may only reinforce his or her feelings of helplessness.
People who deliberately self-harm, or who threaten or attempt suicide, evoke strong countertransference responses that can both inform and obstruct treatment. These include denial, anger and impulses to rescue the person. Some guidelines for the management of the person who repeatedly self-harms
As a group, these are among the most difficult people to treat. They evoke strong countertransference responses that can both inform and obstruct treatment. Often these people have been the victims of childhood abuse. A more detailed discussion of management issues can be found in Chapter 23 in the section on borderline personality disorder. Below are some suggestions about how you might approach the management of a young woman who repeatedly presents to you with ideas or acts of self-harm. 1. Focus on the here-and-now issues surrounding the current crisis rather than going over past problems, including those of past abuse. Leave dealing with those issues to her psychotherapist. Try to identify the precipitating problem and use structured problem solving techniques to resolve it. Sometimes the precipitant may not be an event, but rather an unpleasant affective state, for example, a feeling of emptiness or boredom. She may have great difficulty accounting for her actions. Nevertheless, persist in seeking to understand what the act means to her.The initial goal of therapy is to find alternative ways of dealing with such crises. 2. Reach an agreement about ensuring her safety using the principles outlined above. If the plan breaks down, use structured problem solving techniques to revise and improve it. 3. Set explicit limits about what you can and cannot do. Acknowledge that while you are concerned about her self-harming behaviour and wish to help her, her safety is ultimately in her own hands. 4. As a corollary, do not be drawn into desperate attempts at rescue. You may only reinforce the young womans feelings that she is helpless and cannot take responsibility for her own safety.You run the risk of becoming burnt out or of being drawn into desperate attempts at treatment that may only worsen the problems. 5. Do not be too critical of others involved in her treatment. Talk to them and work together with them towards common goals. 6. Monitor your countertransference and acknowledge negative feelings and impulses. By doing so, you will be less likely to act out upon them. 7. She may at times present a paradox. After just having harmed herself, she may present with a bland, even smiling affect. Do not collude with this denial. Always remain serious and realistically concerned about her dangerous behaviour. Do not joke with her about her selfharming behaviour.
Always remain serious and realistically concerned about a persons suicidal behaviour. When a patient commits suicide
Sadly, despite our best efforts at prevention, there are some people who will commit suicide. It has been estimated that, on average, general practitioners will lose a patient by suicide around once every six years1. Note, however, that this figure varies from one practice to another. In the aftermath of the suicide of a patient under your care, it is advisable to contact the family
1
Office of Health Economics. Suicide and deliberate self-harm. London: Office of Health Economics, 1981.
A Manual of Mental Health Care in General Practice 31
and offer to meet with them. Encourage discussion and ventilation of feelings. Acknowledge that the grieving process after a suicide may be particularly painful, with conflicting emotions of sadness, guilt, shame and anger (see Chapter 7). Consider attending the funeral. Contrary to what you might expect, families are generally grateful for your attendance and are unlikely to criticise you. An audit of the case should be conducted with a group of colleagues. The focus should be on a supportive review and what can be learned rather than on what went wrong. It is essential to seek the support of a colleague at this time (see Chapter 25).
Dangerousness
One of the reasons for the stigma of mental illness is the commonly held belief that people with mental disorders are dangerous. In fact, most individuals with mental disorders are not violent and present no threat to others. In particular, the depressed and anxious people who are commonly seen in general practice are probably less dangerous than people in the community at large. However, it is true that, as a group, people with mental illnesses are around three to five times more likely to commit acts of violence than the rest of the population1. This increased risk should be understood in contextit is about the same as that for young men. Moreover, what is true for a group does not necessarily pertain to an individual member of that group. For example, a young, isolated and unemployed man with schizophrenia who has a history of violence and substance abuse and is currently delusionally jealous presents a relatively high risk. By contrast, an elderly woman with well-controlled schizophrenia, who has strong social supports and no history of violence, presents a minimal risk of dangerous behaviour. With potentially dangerous or violent persons, the main goals, in order of priority, are: 1. self-protection 2. prevention of immediate violence 3. diagnosis and assessment of the risk of dangerousness 4. development of a treatment plan that includes measures to minimise the likelihood of future violence.
Self-protection
Assume that violence is always a possibility and never allow yourself to be surprised by a sudden, violent act. Know as much as possible about a person before seeing him or her. It is especially important to know if the person has a past history of violence, and whether the person has access to firearms or other weapons. Never interview an armed person. Never interview a potentially violent person alone or in a room with the door closed. Never use a room with an internal manually operated lock. Consider removing neckties, necklaces or other articles of clothing or jewellery that the person can grab or pull. Stay within sight of other staff members. Do not attempt physical restraint yourself. Do not give the person access to areas where weapons may be available (e.g. syringes, furniture). A paranoid person may feel threatened if you sit too close. Keep yourself at least at arms length from any potentially violent patient. Do not challenge or confront a psychotic patient. Be alert to any signs of impending violence. In the face of impending violence, leave the room.Trust your own instinct about this. If you feel afraid, then leave. Always leave yourself a route for rapid escape in case the person attacks you. Never turn your back on the patient. A common response of people who are angry is to walk out. Do not obstruct their passage.
Borum R, Swartz M, Swanson J. Assessing and managing violence risk in clinical practice. Journal of Practical Psychiatry and Behavioural Health, 1996, 205-215.
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If you feel afraid during the interview, leave the room. Prevention of immediate violence
The key to prevention is early detection and preventive action. Signs of impending violence include recent violence against people or property, clenched teeth and fists, verbal threats or menacing, wielding weapons or objects potentially useable as weapons, agitation, alcohol or drug intoxication, paranoid delusions and command hallucinations. Be supportive and non-threatening to potentially violent patients. Set limits by offering choices (e.g. medication by alternative routes) instead of provocative directives (e.g. Take this medicine now.).Tell them directly that violence is not acceptable. Reassure them that they are safe. Convey an attitude of calm and control. If medication is offered, the person should be told that the aim is to help him or her relax and gain more self-control. If medication is needed, choose the least invasive route that is practical.
Psychiatric diagnosis alone is a poor predictor of violence. Risk factors include a statement of intent, a specific plan, the availability of means (especially firearms), male sex, youth (1524 years), a history of violence and other antisocial acts, poor impulse control, abuse of substances (especially alcohol and amphetamines), low IQ, family history of violence, history of childhood abuse, low socio-economic status, poor social supports, history of suicide attempts and recent psychosocial stressors.
McNeil DE, Eisner JP, Binder RL. Relationship between command hallucinations and violence. Psychiatric Services, 2000, 51:12881292. 2 Cheung P, Schweitzer I, Crowley K, Tuckwell V.Violence in schizophrenia: role of hallucinations and delusions. Schizophrenia Research, 1997, 26:181190.
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Treatment plan
Treat the underlying mental disorder and take steps to reduce the risk of future violence. 1. Warn the intended victim of any violent threat. Phone the police, the person under threat, or his or her family or friends. The duty to warn takes priority over patient confidentiality. 2. Restrict the persons access to weapons (especially firearms). A firearm prohibition order can be arranged by writing to the police. 3. Treat any underlying mental disorder, if necessary, in hospital, under regulation. 4. If violence is related to a specific situation or person, try to separate the two. 5. If there is no evidence of a mental disorder, ask the person to leave and, if necessary, contact the police.
If a person makes a direct threat against another, the duty to warn overrides the need to maintain confidentiality.
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Chapter 4
Transcultural mental health issues
Culture and mental illness
Helman defines culture as a set of guidelines (both explicit and implicit) which individuals inherit as members of a particular society, and which tells them how to view the world, how to experience it emotionally, and how to be behave in it in relation to other people, to supernatural forces or gods, and to the natural environment.1 Different cultures have different views on what constitutes mental illness.The definition depends on what is regarded as normal and abnormal, and whether or not behaviours are within the norms of the particular society. Mental illness is applied to those behaviours that are both abnormal and outside these norms. Criminal behaviour is viewed as normal, but against the norms of society. Certain abnormal behaviours are sanctioned in specific circumstances (e.g. speaking in tongues or, in our society, the behaviour of footballers after winning a game). The Western concept of mental illness tends to locate the problem within the individual sufferer, whilst in many non-Western cultures, the problem is seen as belonging to the community as a whole. There is a tendency within Western medicine to attempt to reduce illness to a single, often physical cause. Psychoanalysis tends to reduce illness to experiences in the mind of the individual. A theme of this book is to avoid such reductionism and to consider the range of biological, psychological and social factors in the formulation of mental disorders. In many societies, the spiritual dimension is of central importance.
The Western concept of mental illness tends to locate the problem within the individual whilst in many non-Western cultures, the problem is seen to be one of the community as a whole.
The ways that different cultures view mental illness influence their diagnostic systems. While there are similarities in the forms of illnesses across different societies, the content of symptoms and signs are specific to the society. For example, delusions and hallucinations occur in all cultures but their contents differ. An Australian man with schizophrenia may complain that his thoughts are being influenced by laser beams, while a man from Fiji may complain of black magic interfering with his thoughts.
The forms of mental phenomena are similar in different societies, but their content is specific to each.
A persons culture also influences the manner in which he or she presents mental health problems. In some cultures, psychological distress is more commonly expressed through somatic complaints than through mental symptoms. Some languages have a paucity of words to describe emotions and other subjective experience. The way that people present their problems and seek treatment is shaped by their culture, and the symptoms and signs tend to fall into patterns recognised within it. The sick role is defined by a number of culturally specific entitlements and obligations of the person who is ill.
Helman C. Culture, Health and Illness. 2nd Edition, London: Wright, 1990.
A Manual of Mental Health Care in General Practice 35
In Western societies, a high priority is placed on confidentiality. As a corollary, people with mental health problems are often stigmatised and treated in isolation from the rest of their community.
By contrast, the involvement of the community in both the formulation of the problem and in its treatment in non-Western societies means that the person, rather than being excluded from society, becomes instead a focus of community attention and support. Indeed, the process of healing is often a powerful cohesive force within these societies. This may, in part, explain why people in non-Western societies who suffer psychotic illnesses have a better prognosis than people in the West. Treatments in non-Western societies usually involve the family. In the West, deinstitutionalisation has meant that a greater responsibility for care falls on families who are now routinely involved in treatment.
The better prognosis of psychosis in non-Western societies may in part be due to the involvement of the community in both the formulation of the problem and its treatment.
There are certain common features of non-pharmacological treatments across different cultures. All involve a mythic belief system that the healer communicates to the sufferer. The healer makes links between the myth and the problems of the individual. The individual is engaged emotionally in the treatment.Therapeutic change is achieved by reframing the problem in terms of the myth. The person gains a sense of mastery and a new explanatory narrative of his or her experience. This is as true of psychoanalysis as it is of various forms of spiritual healing in nonWestern societies.
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On-site interpreting
Before the interview, make sure that extra time has been set aside for the consultation with the interpreter. When complex information needs to be communicated, it is wise to brief the interpreter before the interview. During the interview, always speak directly to the person, addressing him or her in the second person. Avoid having the conversation with the interpreter. At the beginning of the interview, introduce yourself and the interpreter and explain your roles. Explain that the interview will remain confidential. During the interview, speak slowly and
A Manual of Mental Health Care in General Practice 37
use short sentences in plain English. Pause after two or three sentences to allow the interpreter to communicate what you have said. Summarise the discussion periodically throughout the interview. At the end of the interview, ask the person if he or she has any questions. Consider debriefing the interpreter after the interview.
Always use an interpreter in a face-to-face interview when gaining consent for surgical or other procedures.
Mathews JD. Aboriginal Health Issues. Report to Senator Graham Richardson from the Menzies school of health research, Darwin, Northern Territory: 1993. 2 Clayer JR, Divakaran-Brown CS. Mental Health and behavioural problems in the urban Aborginal population. Report of a study conducted by the Aboriginal Health Organisation and the mental health evaluation centre of the South Australian Health Commission, 1991. 3 McKendrick JH. Patterns of psychological distress and implications for mental health service delivery in an urban Aboriginal general practice population. Thesis: Doctor of Medicine. University of Melbourne. 4 Queensland Health. Queensland Mental Health Policy Statement for Aboriginal and Torres Strait Islander people. Brisbane: Queensland Health, 1996.
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There is a high prevalence of depression and anxiety. In a study of one community in Adelaide, 25 per cent of Aboriginal adults had attempted suicide at some time in their lives1. The rate of suicide for indigenous young men between the ages of 15 and 24 is three and a half times higher than for other Queensland men in this age group2. Rates of alcoholism are high with levels between 32 per cent and 65 per cent reported in men, and between 3 per cent and 51 per cent in women, in different communities3. Among children and young people, there is a high prevalence of conduct disorder. The rate of incarceration among 15 to 19 year old boys is 25 times that of non-indigenous youth. There are also high rates of alcohol and substance use (including marijuana and petrol sniffing) among indigenous youth. The severe social disadvantage under which many indigenous Australians live may partly explain these high rates of mental disorders. As a group, indigenous people are poorly educated, live in overcrowded conditions, suffer a low standard of housing, and have high levels of poverty and unemployment. Their physical health is poor. Families are disrupted with high rates of parental discord, domestic violence and substance abuse. Children frequently suffer neglect and abuse.
Severe social disadvantage may partly explain the high rates of mental disorders amongst indigenous people.
The current social situation of indigenous Australians can be understood in terms of the history since white settlement. Throughout the world, the worst outcomes for indigenous peoples following colonisation have occurred when there has been no formal treaty or settlement regarding the transfer of lands, and where the national government has not been in control of indigenous affairs. In Australia, there were no treaties, and the Federal Government only took over responsibility for indigenous affairs after the referendum in 1967. In the early days of white settlement, Aboriginal families were forced to move away from their traditional lands to make way for farmers and other settlers. They were often resettled on land that was far from their homelands, in places where they could not practice their traditional ways of life. In the process, extended family groups, fundamental to indigenous culture were often broken up. Government and church agencies took over many of the traditional roles of people in these communities and so further contributed to the loss of identity suffered by these displaced people. Up until the mid 1960s many indigenous children, especially young girls, were taken from their families and brought up in orphanages or within non-indigenous households. The separation of young people from their families continues to this day with many young men being incarcerated in juvenile justice facilities. In a recent Victorian study, 49 per cent of respondents had been separated from both of their parents for significant periods of time before they were 14 years old4. The impact of these events is evident today. The multiple losses suffered as a consequence of colonisationthe loss of land, family connections, culture and healthhas had a profound effect on the identity and consequently on the health of indigenous Australians. The anger of many young Aboriginal men can be seen as a response to these events. In the face of this loss of identity, many turn to alcohol.
Radford AJ, Harris RD, van der Byl M, et al. Taking control: a joint study of Aborginal social health in Adelaide with particular reference to stress and destructive behaviours, Monograph 7, Department of Primary Health Care, Flinders University of South Australia, Adelaide, South Australia, 1991. 2 Baume PJM, Cantor CH, Mc Taggart PG. Suicides in Queensland: a comprehensive study, 1990-1995. Brisbane: Australian Institute for Suicide Research and Prevention, 1998. 3 Hunter EM. Aboriginal Health and History: Power and Prejudice in Remote Australia. Melbourne: Cambridge University Press, 1993. 4 McKendrick J, Cutter T, Mackenzie A, Chiu E. The pattern of psychiatric morbidity in a Victorian urban Aboriginal general practice population. Australian and New Zealand Journal of Psychiatry 1992; 26:40-47.
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The multiple losses suffered by indigenous people as a result of colonisation have had a profound effect on Aboriginal identity.
Indigenous cultures recognition of mental illness is demonstrated in language. There are many Aboriginal words to describe abnormal mental states and behaviours (e.g. womba and wangi wangi). Moreover, there appears to be a high tolerance of abnormal behaviour. Disturbed people are usually cared for by their families with women often having to carry the main burden of care. Aboriginal and Torres Strait culture has a holistic concept of health, embracing not just physical and mental health, but also cultural and spiritual well being. Disturbance in an individual is viewed as reflecting a community problem. Mental disturbance, especially when severe, is often seen as a spiritual problem and spiritual treatments may be used. Traditional healers play a vital role in the care of indigenous people with mental health problems.
Aboriginal culture has a holistic concept of health, embracing not just physical and mental health, but also cultural and spiritual well being.
When treating an indigenous person with a mental health problem, be mindful of cultural differences. A failure to do so may lead to misdiagnosis. Culturally normal behaviours may be mistaken for psychotic symptoms and be treated inappropriately with antipsychotic medications. On the other hand, important symptoms of distress may be mislabelled as normal cultural variants. If possible, engage the services of a local indigenous community member or health professional to assist the assessment and ongoing care. There are no formal guidelines or protocols put forward by Queensland Health for the assessment and treatment of an indigenous person who is suffering a mental health problem. However, consider the following suggestions that are taken from a training video1. 1. Set aside extra time. The interview is likely to take longer than usual. 2. Explain your role and the sort of things you are going to ask. 3. Remember that you may be viewed as a member of a culture that has caused damage to indigenous cultureanticipate some anger, resentment or suspicion. 4. Be careful about using direct questions. They may be perceived as threatening and intrusive and be met by a hostile response. 5. Avoid using medical and other technical jargon. 6. Recognise that vague and non-specific answers may reflect the discomfort of the person being interviewed. 7. Indigenous people may avoid direct eye contact.This is regarded as polite within indigenous culture. 8. Be aware of the following cultural prohibitions: referring to a dead person by name referring to certain close relatives by name (for example, a Torres Strait Islander male may not refer to his brother-in-law by name) criticising an elder (older people are treated with great respect within traditional cultures) confiding certain personal information to a member of the opposite sex (mens and womens business are usually kept separate) criticising members of the extended family (family loyalties are strong).
Audiovisual services. Last night I heard a voice:Working with Indigenous Mental Health Clients. Queensland Government, 1996.
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9. In assessing the mental state of an indigenous person remember the following: Hallucinations may not necessarily be psychotic phenomena. For example, it is normal for the bereaved to see and hear the voice of a deceased family member. Other family members are also likely to share the experience, which is usually perceived as reassuring. These phenomena usually do not persist longer than a month after the relatives death. Limited eye contact, and softly spoken and brief answers may merely indicate that the person is shy or being polite. Anger and obscene language directed at you may reflect past experience by that person, or his or her family, of exploitation and hardship inflicted by members of your own culture. 10. Consider carefully the appropriateness of any cognitive tests that you use.Take into account the education and living situation of the person being tested.Tests such as counting backwards, spelling and remembering a sentence may be perceived as demeaning and precipitate a hostile response.
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Chapter 5
Family and marital problems
Many of the mental health problems seen in general practice are problems in couples, or in families, rather than in an individual. In cases where an individual suffers a mental illness, the impact of the illness on the family, and the way that family factors affect the person with the illness, are important components in the assessment and treatment. General practitioners are not expected to provide formal family therapy or relationship counselling. However, they need to be confident in assessing and formulating family and marital problems, and in providing basic counselling and appropriate referral.
Family problems
Family perspective
Family assessment requires a change in perspective from viewing an individual with a mental disorder to viewing the interactions within a social system in which difficulties exist. When one member of a family does suffer a mental (or physical) illness, this wider perspective encompasses not only the way that the illness affects the individual, but also the meanings that other members of the persons family ascribe to his or her behaviour, how they respond, how their behaviour feeds back on to the individual and on other family members, and the impact of the familys response on the persons illness. One looks for circular patterns of causality (abc ---a), rather than simple linear causality (ab).
In assessing a family system, look for patterns of circular rather than linear causality. Family functioning
Individuals are members of a wide variety of social systemsat school, at work, and in recreation and sporting clubs. People with chronic mental disorders belong to systems of mental health care that include mental health staff, rehabilitation agencies and general practitioners. The most fundamental social system to which we belong is the family. There are a number of ways of viewing the structure and function of families: The commonest structure in our society is the nuclear family. However, a large number of variants exist, including the single-parent family, the extended family and the blended family. Like individuals, families undergo developmental changes throughout their life cycle. There are wide variations, but some of these are as follows: two young people leave their families of origin, meet, become engaged and marry; the first child is born, and second and subsequent births follow; the first child starts pre-school and then moves on to primary school; the youngest child starts school, leaving no children at home during school hours; the children pass through adolescence, develop greater autonomy, form intimate relationships outside the family of origin and leave home; and the final period between the parents retirement and their death. Each of these transitions requires individual family members and the system as a whole to change. Illness and other significant stressors can interfere with this developmental process. On the other hand, developmental changes may precipitate mental illness in an individual.
A Manual of Mental Health Care in General Practice 43
A family, like an individual, undergoes developmental changes throughout its life cycle.
A familys cohesiveness is evident in the loyalty of individual members to each other and their ability to work together. It is compromised when there is severe conflict between family members, when opposing alliances form or when one member is made a scapegoat. Each generation influences subsequent generations. The way that a man is reared affects the way he rears his own children. Aspects of the identity of a family as a whole are also passed on to the next generation. In some families, a myth about the family is handed down from one generation to the nextfor example, that The Smiths are a stubborn lot. Within the family system are a variety of subsystems. In well-functioning families, the strongest bond is that between the parents. Other subsystems include those between the children, between members of the same sex, and between those sharing common interests. Problems can arise when one subsystem is in conflict with another, for example, when a mother and her daughter begin making family decisions more appropriately the responsibility of the parents. Boundaries between subsystems need to be both clear and flexible. Patterns of diffuse boundaries, typical of enmeshed families, may produce highly cohesive family units but at the expense of the autonomy of the individual members. On the other hand, families with excessively rigid boundaries may promote individual autonomy but leave the members isolated and unsupported in times of stress.
In families with a limited range of emotional expression, distress may be expressed through the development of somatic symptoms or behaviour problems.
Families differ in how effectively they deal with stressors, whether meeting the normal developmental challenges of their members or coping with other life events. Following a stress to a social system, such as a family member developing a mental illness, the system changes and eventually reaches a new equilibrium, a process analogous to the functioning of physiological systems in maintaining homeostasis. Stressors may be external to the family (e.g. financial difficulties or unemployment of a principal breadwinner) or internal (e.g. the developmental challenges of individuals or of the family as a whole, or illness of a family member). Stressors may be adverse (e.g. the death of a family member) or benign events (e.g. the birth of a child). Families may grow in response to a challenge or be set back.
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A well-functioning family meets the normal dependency needs of its members while, at the same time, promoting each individuals autonomy.
The family provides a model of socialisation that can be transferred to relationships in the outside world. Specifically, the parents provide models for identification by the same-sex offspring.
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A woman with delusional disorder believes that the neighbours are involved a criminal group that facilitates illegal migration to Australia. Since giving information to the police, she is convinced that her own life is at risk. She insists that her 10-year-old son stay home from school in case he is abducted. The boy has also begun to believe that the neighbours are a threat to him. In the face of caring for his wife who suffers dementia, a man develops major depression.
A woman with obsessivecompulsive disorder insists that her husband assist her in her rituals. At times, he is up until 1.00am as she completes her showering and cleaning rituals before going to bed. Since the onset of Stevens schizophrenic illness, his mother has become his principal support. His 16-year-old brother has been increasingly resentful of the attention that Steven receives and he complains that nobody is interested in anything that he does. He is threatened with suspension from school because of rudeness to teachers and fighting.
Physical illness can also interfere with normal developmental tasks of individuals within a family.
Andrew is a 15-year-old young man whose diabetic illness has been poorly controlled recently. His parents are anxious and upset. Until recently, they carefully monitored his blood sugar and insulin dose. However, over the past three months, he has resisted their involvement, insisting he will manage his insulin himself. Comment: Andrews developmental demands for greater autonomy are in conflict with the limitations placed on him by the illness and by his parents desire to maintain some surveillance and control over the treatment. His distress is expressed through his poor compliance.Treatment would involve seeking an agreement with his parents that he will take greater control of his treatment, and to help Andrew grieve the losses and the limitations associated with having the illness, to gain a greater acceptance of it and to improve his compliance with treatment.
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In interviewing families, it is important to respect the existing power structures within the family, but at the same time to facilitate each individual having his or her say. A useful technique is circular questioning in which each individual is asked in turn his or her opinion on the particular matter in question, and then to respond to what the others have said
Having a strong liking or dislike for a family member can interfere with therapy. Indications for family therapy
child and adolescent emotional or behaviour problems family member with a serious mental disorderin particular, a person with schizophrenia living in a family with high levels of expressed emotion, or a girl with a recent onset of anorexia nervosa families in crisis families in which the developmental tasks of its members are delayed when family factors are causing, maintaining or exacerbating an individuals mental illness families with boundary problemsfor example, enmeshment or isolation families with serious communication problems.
Contraindications
where there are cultural prohibitions child sexual or physical abuse In such cases the priority is to ensure the safety of the victim. Confronting the perpetrator in family therapy mislabels the problem as a family problem and may lead him or her to retaliate against the person who discloses the abuse.
Marital counselling
Around 40 per cent of marriages in Australia end in divorce. The break-up of a marriage is one of lifes most stressful events. The annual cost of marital difficulties in Australia has been
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estimated to be two billion dollars a year1. Twenty per cent of assaults reported to the police and twenty-five per cent of murders occur between spouses. People suffering marital distress pay more frequent visits to their general practitioners, sometimes with ill-defined somatic complaints. Marital distress is associated with higher rates of depression, substance abuse, sexual dysfunction, marital violence, accidents, heart disease and cancer. The children of couples with marital problems are prone to behaviour problems, school problems and depression. Children who witness parental violence are at risk of entering abusive relationships later in life, as victim or abuser.
Marital distress is associated with higher rates of depression, substance abuse, sexual dysfunction, marital violence, accidents, heart disease and cancer. Presentation
One or other partner may present to you because of the marital problem. However, in many cases he or she will present with some other problemill-defined physical symptoms (headaches, gastro-intestinal symptoms), substance abuse, injuries, depression or sexual problems. Children of troubled couples may be brought to see you because of depression or behaviour problems.
Formulation
Problems in marriages can be viewed from a number of perspectives. Using a systems approach, one considers the interactions between the couple rather than looking for a problem in one or other individual. Instead of seeking a single cause of the problem, one looks for circular patterns of causality in which one event triggers others that eventually feed back on the original event. Individuals may have different expectations of their relationship. For example, a man may be distressed because his wife does not share aspects of her life with himher work, the time she spends with her female friends and her sporting activities. There may be communication problems. Partners may be unable to discuss their difficulties. Marital problems may arise in the face of stresswhen both partners are unemployed, when a member of the family suffers an illness, or at times of developmental change within the family, such as the birth of a child. From a psychodynamic perspective, one may see patterns in relationships that cross generations. For example, the man who has a conflicted relationship with his mother may unconsciously behave towards his wife in the same way as he does towards his mother. Here, the image he has of his wife is in conflict with her real identity. Instead of recognising and confirming her identity, he coerces her to conform to his image of her.
Marital therapy
One of the prerequisites for performing marital therapy is that the therapist is disinterested, taking sides with neither partner. For the general practitioner, this is often impossible as he or she is already treating one or both partners for individual problems and is a confidante of each. In such cases, referral should be made for marital therapy. Organisations offering this service include Relationships Australia, Lifeline, Catholic Family Services and other counselling centres. The main role of the general practitioner is in the detection of marital problems.You may also provide information to the couple about the resources available to help them, including written material2. Use counselling and structured problem solving to help deal with crises. In cases of
Wolcott I, Glazer H. Marriage Counselling in Australia: An Evaluation. Melbourne: Institute of Family Studies, 1989. 2 Montgomery B, Evans L. Living and Loving Together. Melbourne:Viking O Neill, 1983.
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marital violence, provide information about crisis support and accommodation, social security and legal sanctions. Indications for referral for marital therapy include chronic, multiple and severe problems, limited problem solving capacity, and associated mental disorder (depression, substance abuse) in one or other partner. Some techniques used by marital therapists are listed below. The focus is generally on the relationship and interactions between the partners rather than on one individuals problems. The couple are often asked to sit facing each other rather than the therapist. This facilitates direct communication. Circular questioning involves the therapist asking one person a question about the other, and then asking the other to respond. In reciprocal negotiation, a complaint of one partner is re-formulated as a wish. A task that fulfils this wish is then negotiated between the two. The other person is also given the opportunity to express a wish, and a task is then agreed upon to realise it. The therapist carefully observes the way that the couple communicate, noting problems such as those listed below: 1. expressing thoughts in an intellectual, debating style, but without the expression of emotion 2. a lack of empathy for the other 3. failing to listen 4. monologues in which one partner acts as spokesperson while the other submits 5. one partner stating how the other feels instead of allowing the other to state this for him/herself 6. wandering off the topic 7. constant criticism with little positive reinforcement. Generally, the therapist will interpret the communication problem and then ask the couple to rehearse a different style. The therapist may ask the couple to have an argument over some real, though minor, problem. This is a useful way of getting the subservient partner in a relationship to rehearse expressing his or her views and being more assertive. Another technique is for the therapist to ask each partner to role-play the response of the other to a given situation. This enhances empathy. The couple may be asked to set aside time for pleasurable activities or for tasks agreed to in a reciprocal negotiation. Time may be set aside to discuss a particular problem.
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Chapter 6
Crisis intervention, counselling and structured problem solving
Crisis intervention, counselling and structured problem solving are techniques used to help people who are under stress. Stress is a persons response to an event that requires him or her to change. A stressor may be either an adverse event, such as bereavement, or a desirable one, such as a promotion. Likewise, the outcome of facing a stressor can be positive or negative. A person under stress may or may not have an intercurrent mental illness. People with personality disorders are especially prone to stress. Their lives are frequently chaotic, and their maladaptive coping mechanisms mean that they often exacerbate or avoid their problems rather than find effective solutions to them. Some common stressors are listed in Table 6-1.
Stressors include both adverse and desirable events. Table 6-1: Common stressors
1. losses 4. others
bereavement
separation/divorce response to major surgery or medical illness financial loss marriage retirement developmental stage e.g. adolescence, retirement housing
work problems financial problems problems with neighbours
3. relationship problems
Elevated levels of arousal caused by a stressor initially lead to improved coping. However, when the levels of arousal rise above a certain point, coping deteriorates and can lead to decompensation (see Figure 6-1).
Increased arousal initially improves coping, but excessive arousal can lead to decompensation.
The ways of dealing with these two situations are quite different.The person who is under stress receives counselling and is taught structured problem solving (see Figure 6-2), while the person who is decompensated first undergoes crisis intervention.
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Arousal
Decompensation
Crisis intervention:
then
Under stress
Crisis intervention
The aim is to decrease the level of arousal until the person in crisis can return to his or her normal level of coping. As soon as this is achieved, responsibility for the problems is handed back to him or her, and counselling and problem solving can begin. Some of the steps used in crisis intervention are listed below. An example is given in Box 6-1.
Crisis intervention aims to decrease the decompensated persons level of arousal so that he or she can begin to cope effectively with his or her problems.
Temporarily take over responsibility for the problems. Remove the person from the stressful situation. In some cases, it may even be necessary to arrange a brief admission to hospital. Lower the persons level of arousal by listening, encouraging the person to ventilate his or her feelings and providing reassurance. A brief course of a benzodiazepine may sometimes be appropriate.
52 Crisis intervention, counselling and structured problem solving
Diagnose and treat any mental disorder. When the persons judgement has returned to normal, offer counselling and structured problem solving.
Counselling
The aim is for the person to cope as well as possible with the stressor.The problem is not treated as an illness. The person is not treated as being sick but rather as a coping adult. The theory of counselling is that through facilitating the expression of feelings about the stressor in the context of a good therapeutic alliance, the person will be able to clarify and understand his or her problems better and solve them rationally to the best of his or her ability.
Counselling and structured problem solving aim to help people cope to the best of their ability with their problems.
Counselling begins by understanding and clarifying the problem. Some steps you might take in counselling (a woman) are listed below: Listen as she describes the stressful situation or event. Reflect back what she says and clarify her account of what has happened. Allow her to ventilate her feelings. Empathise with how she feels. Try to make sense of any precipitants. These may have special meaning in terms of her past history. For example, the loss of a loved one may rekindle grief over past losses. Take note of any dysfunctional ways of coping, for example alcohol or other substance abuse, aggression or violence. Ask how she has dealt with similar problems in the past. Ask how she has dealt with other stressful events.
Structured problem solving helps people find effective and rational solutions to their problems.
A Manual of Mental Health Care in General Practice 53
You will need to set aside two or three longer consultations (e.g. 25 minutes) in the counselling phase as you assess and define the problems.The other steps can usually be spread over about five 15 minute sessions. However, new problems may then need to be addressed. Most of the work is done by the person (him or herself) at home. Some steps that you might take in assisting a woman with structured problem solving are listed below: Explain the approach described in Table 6-2 and give her a copy of it (Appendix 3). Help to clarify the problem. The problem should be formulated as a specific goal or need. Suggest other possible solutions. Remind her of her strengths and weaknesses. Ensure that she is realistically appraising the different possible solutions. Make sure that she does not rush into action. Help her break down the plan into discrete steps. Help her to check the effectiveness of the action taken and identify any remaining problems. An example of counselling and structured problem solving is given in Box 6-2.
54 Crisis intervention, counselling and structured problem solving
Non-specific stress reduction techniques In addition to the specific techniques discussed above, a number of non-specific techniques can be used to reduce stress. People should be advised to avoid major life changes in the midst of coping with major stressors. They should be reminded of the importance of dealing with problems in their lives rather than ignoring them (e.g. ongoing relationship problems). They may benefit from the controlled breathing, relaxation exercises and self-hypnosis described in Appendices 4, 5 and 6. It may be useful for them to monitor their daily activities and to use a Daily Activity Schedule that includes enjoyable activities and a regular exercise program (see Appendix 7). Advice on avoiding self-medication with alcohol, cigarettes and benzodiazepines and improving sleep habit may also be indicated (see Table 14-3). It may be appropriate to refer people to other specialist agencies that can help with their problems (e.g. for financial counselling).
A note on advice
Rather than help people solve problems themselves, it is often tempting to tell them how to solve their problems. It may save time in the consultation and the solution may seem obvious. However, you should resist this impulse. Telling a man what he should do will reinforce his sense of ineffectiveness and low self-esteem. Since it is the man himself who has to live with the consequences of his actions, he should take responsibility for these decisions himself. If you tell him what to do, he will be less committed to the decision and may blame you if things do not work out well.
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There are exceptions to this rule. As an expert in medicine, you will give advice on the diagnosis, treatment and prevention of illness. During the crisis intervention phase, when a persons judgement is severely impaired and his or her ability to cope is overwhelmed, it may be necessary to take control and advise him or her what to do. In particular, it is often wise to advise people who are in the midst of a crisis not to make major life decisions.You should also advise people what to do in situations in which there is danger to themselves or others.
Structured problem solving aims to help people find solutions to their problems themselves. It is not about telling people what they should do.
Patients often see doctors as authorities, not only on medicine, but on many other matters as well. This attitude may be a manifestation of a paternal or maternal transference. It is flattering to be regarded this way by our patients, but generally inadvisable to act out in the countertransference by telling people how they should run their lives. Some examples of appropriate and inappropriate advice are given in Box 6-3.
and moving interstate. You advise her to delay making such a major decision until the immediate crisis has settled and the advantages and disadvantages of it can be calmly and carefully considered. violence against her.You advise her to take the threat seriously and to call the police if there is any immediate threat of violence.You explain how he can get access to treatment.You also explain the legal protection available (protection or restraining order) and how to access safe houses through Crisis Care.
A woman tells you that her husband, who has delusions that she is being unfaithful, has threatened
Inappropriate advice An elderly woman who was widowed two years ago and whose children live overseas
often asks you for advice on how she should manage her affairs. One day she asks if you think she should sell her house and move to a home unit. Coincidently, you recently decided to invest in the float of a public company that is soon to be privatised. You advise her to sell the house, move to a unit and invest her excess capital in the company. Comment In the transference, she speaks to you as she might have spoken to her husband or her son. In the counter transference, you make the mistake of acting as if you were her husband or son. The appropriate response would have been to use the structured problem solving approach outlined above. Amongst possible solutions, you would ask what her son suggests she should do.
A note on debriefing
Note that debriefing or crisis intervention alone is ineffective in preventing later psychological sequelae following a traumatic event. While those who are exposed to trauma have a high risk of later developing a psychiatric disorder, most who do so do not suffer an acute stress reaction at the time of the event. The key is in long-term observation and early intervention. General practitioners are well placed to do this.
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Chapter 7
Grief counselling
In the last chapter, I discussed the principles of counselling and structured problem solving. Here, I describe the application of these principles to two specific situations that are common in general practicecounselling the bereaved and giving people bad news. Both involve helping people deal with grief, the response of a person to loss. Bereavement, physical and mental illness, redundancy, unemployment, relationship breakdowns and other stressful life events involve significant losses, including a loss of the ability to carry out valued activities, and losses of earning capacity and independence. Whereas grief refers to the individuals response to loss, mourning is the process that people go through after a loss. It involves a number of tasks as discussed below. The general practitioner should avoid pathologising what is a normal mourning process. On the other hand, he or she needs to recognise and intervene when the mourning process is abnormal, or when a person develops a mental disorder.
Whereas grief refers to the individuals response to loss, mourning is a process involving a number of tasks.
Bereavement
Normal grief
Normal grief may involve a variety of feelings, thoughts, behaviours and physical symptoms. Some of these are listed in Table 7-1.
Tasks of mourning
Worden1 describes the following four tasks of mourning: 1. Accepting the reality of the loss
While it is normal for the bereaved to exhibit some denial of the loss, it is abnormal for the denial to persist. Denial may be manifest in a number of ways. The room of the deceased may be left as it was at the time or his or her death. The bereaved may lay out his or her clothes each morning. Alternatively, all reminders of the deceased may be removed from the house. These behaviours will cease when the reality of the loss is accepted.
2. Experiencing the pain of grief Every individual experiences grief in his or her own way, and no individual will experience all of the symptoms and signs listed in Table 7-1. However, in the process of mourning, every individual needs to experience the pain of grief. Grief is often complicated when the relationship with the deceased was characterised by marked ambivalence: the person may feel guilty that they had often wished ill of the deceased. An inability to acknowledge anger with the deceased may result in the anger being displaced onto other family members or yourself.
Worden JW. Grief Counselling and Grief Therapy. London: Tavistock Publications, 1983.
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Table 7-1: Feelings, thoughts and behaviour associated with normal grief
Feelings
shock and numbness This commonly occurs immediately after the death and is accompanied by feelings of disbelief. sadness anger For example, a man may feel angry with his wife for abandoning her. The developmental origins of the anger of the bereaved can be seen in the protest that a child exhibits when separated from his or her caregiver. The anger may also be understood as an expression of the persons frustration in being unable to prevent the loss. guilt People often feel guilty that at the time of the persons death, they had not done something to save him or her. anxiety The bereaved may fear that they will not be able to cope without the deceased.They may have a heightened awareness of their own mortality. loneliness yearning The person longs to be reunited with the deceased. relief People in difficult relationships may experience some relief on the death of their partner. When the deceased suffered a long and distressing death the bereaved may be relieved that his or her suffering is over.There may be also be relief when the deceased suffered a long and burdensome illness such as dementia. disbelief This is a common response on hearing of the death. poor concentration The person is preoccupied and distracted. preoccupation with the deceased The person is constantly thinking of the deceased. hallucinations The person may see images of the deceased, especially early in the mourning process. sighing and crying vegetative function change People who are grieving may suffer some transient sleep and appetite disturbance. Their concentration may be impaired and they may be absent-minded. (Persistent neurovegetative symptoms suggest a diagnosis of major depression). interpersonal withdrawal The person may withdraw from social contacts. dreams of deceased reminders of the deceased Some people may avoid reminders of the deceased, while others become particularly attached to photographs, clothes, jewellery and other mementos of him or her. They may visit places of special significance to the deceased. searching They may call out the name of the deceased and search for them. activity level Some people become withdrawn and inactive while others may be restless and overactive. culturally specific responses In Anglo-Saxon cultures, there is generally less emotional display than in southern European cultures. In an Irish wake the bereaved eat and drink, and talk about good and bad memories of the deceased. In traditional Maori cultures, the body is viewed in an open casket in the home of the bereaved. In the Kaluki tribe in New Guinea, feelings of sadness and anger are combined with a feeling that compensation is due for the loss. In Iran, there is often a display of righteous anger, and an identification with the families of religious martyrs1. hollowness or churning in the stomach tightness in the chest or throat depersonalisation breathlessness weakness and fatigue sensitivity to noise; inability to block out background noise
Thoughts
Behaviour
Physical symptoms
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3. Adjusting to a world without the deceased The nature of the adjustment will depend on the role that the deceased played in the persons life. For example, a young widow may have to get used to coming home to an empty house and caring for the children on her own. These issues often come to the fore at around three months after the death. At this time, social supports have often fallen away and the person is facing the task of getting on with life without the deceased. 4. Withdrawing from the deceased and forming new intimate relationships The final task is to detach from the deceased and to form a new intimate relationship without feeling that the memory of the deceased is in some way being dishonoured.
Four tasks of mourning include accepting the reality of the loss, experiencing the pain of grief, adjusting to a world without the deceased, and withdrawing from the deceased and forming new relationships.
The completion of these tasks of mourning usually takes at least a year after the death of a loved one, and sometimes between three and four years.
Abnormal grief
Grief is abnormal when it is chronic, delayed, exaggerated or masked. 1. Chronic grief The normal mourning process following the bereavement of a loved one commonly lasts at least a year. When it persists too long, the person is likely to present for help or be brought to see you by the family. 2. Delayed grief A delayed grief reaction occurs when a person has been unable to complete the tasks of mourning following the death, and instead suffers intense feelings of grief some time later. 3. Exaggerated grief Grief may be exaggerated when the experiences cause intense suffering or become symptomatic of a mental disorder. 4. Masked grief Rather than present with the normal feelings associated with grief, people may react by developing persistent physical symptoms.These sometimes mirror the symptoms suffered by the deceased. In other cases, the pain may symbolise the grief.
Past history
The person with past complicated grief reactions or episodes of depression is at risk.
Personality factors
The obsessional person may have difficulty working through the pain of grief and dealing with the loss of control. The narcissistic person who avoids being dependent on others may have difficulty dealing with the pain of grief. The dependent person may be overwhelmed with feelings of helplessness.
Social factors
People who perceive that they lack social supports, or whose social supports deny or cannot discuss the loss (e.g after suicide) may also be at higher risk.Those who experience other significant life events around the time of the death may have difficulty working through the tasks of mourning.
Features that suggest a diagnosis of depression include severe and prolonged feelings of worthlessness and low self-esteem, suicidal ideation, pervasive feelings of guilt that do not merely relate to the immediate circumstances of the death, prolonged and severe psychomotor agitation or retardation, hopelessness, panic attacks and other anxiety symptoms, and psychotic symptoms. Table 7-3: Signs of abnormal grief
The person, long after the event, is unable to speak of the loss without experiencing fresh painful feelings. The person over-reacts to minor triggers, such as watching a movie. The person fails to remove the possessions of the deceased. For example, the widow who, two years after her husbands death, still lays his clothes out for him every morning. The person avoids memories of the deceased. For example, the bereaved may not have attended the funeral or have visited the grave. The person presents to you with physical symptoms identical to those suffered by the deceased. The person continues to suffer considerable disability and handicap for longer than a year after the death. Themes of loss constantly crop up in the persons conversation.
Worden makes a distinction between grief counselling, which involves helping the bereaved accomplish the tasks of grief, and grief therapy, which uses specialised techniques to help people with complicated or abnormal grief reactions1. For the sake of brevity, I discuss the techniques of both counselling and therapy together. Education People will often be relieved simply to know that their experience of grief is neither abnormal nor evidence of a mental illness. Assisting people to accomplish the four tasks of mourning 1. Techniques used to help a person confront the reality of the loss include talking in detail about the events surrounding the persons death and about his or her relationship with the deceased.You might ask the person to bring in mementos of the deceased and discuss their meaning.
Talking in detail about the events surrounding the death and the persons relationship with the deceased helps the bereaved accept the reality of the loss.
2. People often have difficulty dealing with anger and guilt associated with grief. Anger is especially prominent when the bereaved was very dependent on the deceased. The person feels anger at his or her abandonment. Explore the nature of the relationship. Encourage them to express their feelings. Help the person problem-solve new ways of coping. Anger is also prominent when there is someone to blame for the death, for example after a vehicle accident.
People often have difficulty dealing with anger and guilt associated with grief.
People whose relationship with the deceased was markedly ambivalent often experience painful guilt during their bereavement. At times, they may even have wished the person dead. Help them acknowledge their ambivalent feelings about the deceased. Talk about the death and the persons relationship with the deceased. Encourage the expression of negative affects. Explain that it is normal to have negative as well as positive feelings about people, and that to express ones anger with the person does not diminish the positive feelings one has. A specific technique is to encourage the person to talk about the things they miss, and then the things that they do not miss about the deceased. In some cases, people feel guilty that they were unable to prevent the death.The person will usually come to realise that, in reality, there was nothing that he or she could do. In cases where there is some real reason for the guilt, it is a question of the person acknowledging what they did or did not do. In some cases, they may benefit from addressing the dead person and apologising for their actions. You might ask the person to address the deceased as if they were in the room. This can be facilitated by asking the person to imagine that the deceased is seated in an empty chair. 3. Use structured problem solving to help the person cope with the practical challenges of living without the deceased (see Chapter 6). 4. Encourage the person to form new relationships. Anniversary reactions Grief may recur at specific times after the deathat three months, when the practical challenges of coping without the deceased are becoming evident; on anniversaries and birthdays; and at holiday times.
Worden JW. Grief Counselling and Grief Therapy. London: Tavistock Publication, 1983.
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Maladaptive coping Take note of any maladaptive ways of coping, such as excessive alcohol consumption or cigarette use. Reassurance Avoid bland reassurance (see Chapter 2). Physical examination Be aware of the physical symptoms that are a feature of normal grief, but do not disregard the possibility of physical illness. Medication A short course of a benzodiazepine may be indicated for insomnia early in the period of mourning. Antidepressants should not be prescribed unless the process is clearly abnormal and the diagnosis of major depression is made. Effect on the family system Consider the bereavement not only in terms of the individual who presents to you, but from the perspective of the family as a whole (see Chapter 5). Transference and countertransference Feelings that the bereaved holds for the deceased may be displaced onto the therapist. These include anger at being abandoned and guilt at the bereaved persons inability to prevent the death. Within the countertransference you will experience a number of painful feelingsthe frustration and helplessness of not being able to cure the person with a terminal illness; the pain of witnessing the suffering of others; the response to negative feelings being displaced onto you by the bereaved. Dealing with losses of others will activate feelings about your own losses and feared losses. You will reflect on your own mortality. You are most vulnerable in the countertransference when the patient is similar to you or shares similar experiences. It is important to recognise your own grief when a patient dies. In some cases, attending the funeral may assist your own mourning.
Grief counselling and therapy often uncover strong transference and countertransference responses.
Worden recommends that those who provide grief counselling should take a personal loss inventory. It is important to be aware of ones own limitations and not take on too many patients suffering bereavement. Recognise the sorts of people that you have difficulty dealing with and refer them on. Dealing with death and dying is an exhausting process and can lead to burnout (see Chapter 25). Recognise your own limitations and find out where you can get help if you need it.
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there are others with the patient, ask to be introduced and check with the person whether they are to stay Is it OK if I talk freely about your illness while Gary is here? Begin the interview with an open question, such as How are you feeling?
4. Provide information
First, clarify the persons agenda. What are his or her main concerns? Throughout the interview, you will try to align your understanding of the illness, its treatment and prognosis with that of the patient. Early in the interview, it is often useful to signal that you have bad news to impart Im afraid the situation is more serious than we thought. Information should be provided in small chunks and you should stop frequently to check that it has been understood. Use plain English and avoid medical jargon. Let the persons use of language guide yours. Reinforce and clarify what you are saying.
Acceptability Be tolerant of the persons reactions. In some cases, the person may be angry or even violent. Try to remain calm. Acknowledge the emotion rather than argue the point at issueYou are very upset with this news. Set limitsI want to discuss this with you, but it is difficult while you are pacing the room. Maladaptive versus adaptive Assess whether a response is adaptive or maladaptive. A degree of denial is almost always present at some stage of the response. It is adaptive in protecting the person from being completely overwhelmed by the news. On the other hand, it is maladaptive if it prevents a person receiving
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appropriate treatment or otherwise interferes with his or her ability to cope with the illness. The man who devotes his time to finding a cure for the condition from which he suffers may feel more hopeful, and others may also benefit from his activities. However, the response is maladaptive if it leads him to decline appropriate treatment or if it exhausts him, increases his distress or isolates him from his family and friends.
Open-ended and empathic responses are generally more effective than direct or literal responses.
Avoid false reassurance As mentioned in Chapter 2, reassurance has its place. For example, you may allay a mans fears byreassuring him that you can provide pain relief for his symptoms. However, there may be times when, in an attempt to alleviate a mans immediate distress you are tempted to mislead him. When subsequent events do not go as you predict, the distress will be so much the worse. Answering difficult questions How long have I got? First, clarify exactly what the person means. He or she may not be asking how long before they die, but, for example, how long before they leave hospital. Ask what they understand their prognosis to be. Give the person a ballpark figureIt will probably be from two to three months to five or six months. Acknowledge your uncertainty and empathise with
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the anxiety that this uncertainty causes. Is it terminal? Check what the person means. Ask a man what he understands the prognosis to be. A statement along the following lines may be helpfulI have one patient with the same condition who is still doing well and has had no recurrence after three years. Transference and countertransference Be aware of the transference and countertransference. Communicating bad news is difficult and often painful.Telling a person that they have an incurable illness acknowledges the limitations of medical knowledge. Doctors may have particular difficulty with this task. One of the motivations for entering the medical profession may be a heightened fear of death.You may feel guilty that you neglected something that might have altered the course of the illness.You may resent having to be the messenger of bad news, and the target of the anger and blame that often fall on the messenger. Breaking bad news may not have been included in your medical training. You may also have to deal with difficult transference responses, including flattery and dependency. It is easy to be flattered when a man says that you are the best doctor he has ever had. However, you may regret this later when you struggle to meet the special expectations the person places upon you. It is best to articulate and correct the perception at the beginningIt is nice of you to say that, but, really, this drug is very effective. It is normal for people in distress and under threat to be more dependent. However, it is important not to begin making decisions for the person that are outside your area of expertise and should really be made by that individual, perhaps with advice from his or her or relatives.
Transference responses to receiving bad news include idealisation of the therapist and excessive dependency upon him or her. 6. Planning
At the end of the interview, summarise your understanding of the illness, the treatment and the prognosis, and the specific concerns raised by the patient. Give the person time to ask questions. Make a time for the next appointment.
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Chapter 8
Supportive psychotherapy
For some people with chronic mental disorders, the ability to cope with life challenges is not just temporarily overwhelmed in the face of life stressors, but rather it is chronically impaired. Supportive psychotherapy is indicated for this group of people. Despite the fact that it is a form of therapy that is widely used by psychiatrists, general practitioners and other health professionals, research into it has, until recently, been relatively limited1.
Background
Definition
Supportive psychotherapy is a form of long-term psychotherapy that aims to optimise patients functioning, promote their autonomy, enhance their self-esteem, and lessen their anxiety and distress. Unlike other forms of therapy, supportive psychotherapy does not aim to produce major change in the person. While behavioural treatments aim to alter the way people act, cognitive therapy the way people think, and dynamic therapy the patterns of their defences, supportive psychotherapy aims not to change, but rather to strengthen their existing coping mechanisms.
Supportive psychotherapy is a form of long-term psychotherapy that aims to optimise a persons functioning by strengthening rather than changing his or her existing coping style. Indications
Supportive psychotherapy is the treatment of choice for people with chronic disabling conditions in whom fundamental personality change is not a realistic goal. These people are often severely handicapped, with a limited range of interests and activities, and impoverished social worlds. They are often isolated and what relationships they have are often fraught with conflict. Their ability to cope with the everyday challenges of life is limited and they have few social and other resources to assist them. Included are people with chronic psychotic disorders (schizophrenia, delusional disorder), severe affective disorders (chronic depression, bipolar disorder), anxiety disorders (post-traumatic stress disorder), somatoform disorders (chronic pain, hypochondriasis, somatisation disorder) and personality disorders. However, not all people with these diagnoses require long-term supportive therapy, Many are able to cope well despite their illnesses, and have strong social supports.
Supportive psychotherapy is the treatment of choice for people with chronic disabling conditions in whom fundamental personality change is not a realistic goal. Aims
In view of the severe disability and handicap suffered by these people, the goals of treatment are modest. In some cases, merely maintaining the persons level of functioning is the appropriate
Bloch S. Supportive psychotherapy. In: Bloch S, Ed An Introduction to the Psychotherapies. 3rd ed. Oxford: Oxford University Press, 1996: 294-319.
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goal.The overall aim is to optimise the patients adaptation to living. Specific aims are to optimise their social and occupational functioning, to help them deal as adaptively as possible with life challenges, to acknowledge and cope with their losses, to boost their self-esteem, to improve their reality testing, to monitor their mental states and prevent relapse of their illnesses, to support their families and other carers, to provide a source of comfort and security, to promote their autonomy, and eventually to transfer support from therapy on to the individuals family and other people in their social milieu.
Treatment setting
Unlike the other therapies described in this book, supportive psychotherapy is not time limited but rather long-term. In general practice, sessions will usually be between 15 and 25 minutes. Regular appointments should be made, usually at two or four weekly intervals.You will need to discuss your own availability out of hours and arrange whom the person should contact in an emergency.Where possible, you will speak to family members and other carers.You will need to liaise with other agencies involved in the persons care that may include the local mental health service, employment and housing agencies, and patient and carer support groups.
Techniques of therapy
A number of methods discussed elsewhere in this book are applicable. Basic interview skills are requiredtaking a history, listening, clarifying, allowing the expression of feelings, asking directive psychological questions, using an empathic style, and responding to verbal and nonverbal cues (see Chapter 2). Most important is the ability to listen to the patient, to clarify what he or she says, and to be alert to any significant change, whether for better or for worse.
Basic interview skills are important in supportive psychotherapyhistory taking, listening, clarifying, allowing the expression of feelings, asking directive psychological question, using an empathic style, and responding to verbal and non-verbal cues.
Be aware too of the non-specific aspects of the interview that contribute to the efficacy of therapy: the intense, confiding relationship; the setting in your surgery; the acknowledgment of your credentials as a healer; your ability to instil hope; your provision of new information; the persons emotional arousal in discussing personal events; and his or her experience of improvements in symptoms and functioning1. At different times in therapy you will use crisis intervention and structured problem solving to deal with acute stressors. Various behavioural techniques may also be indicatedfor example, the use of activity schedules and programs of exposure for the treatment of phobias. Many people will be on drug treatments for their mental disorder. The following techniques are used in supportive psychotherapy. Care needs to be taken in their use. I give examples of their appropriate and inappropriate use.
Frank JD. Common features of psychotherapy. Australian and New Zealand Journal of Psychiatry 1972; 6:34-40.
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Supportive psychotherapy
Often in therapy, the best intervention is to listen and do nothing rather than to do something that is ineffective or even destructive. On the other hand, it is important to recognise when a dysfunctional, though stable situation has changed and requires active intervention (see Box 8-1).
Caveat
A 45 year-old woman suffers from chronic schizophrenia. She is of borderline intelligence and demonstrates histrionic and obsessional personality traits.There have been long-term difficulties in the relationship with her husband who also suffers from schizophrenia. The conflicts have usually arisen in the context of her need to be in control and to keep their house tidy, while her husband remains unconcerned about these matters and is not always willing to help. She has been more upset over the past three months. She has been sleeping poorly and has lost the energy to do the housework. She takes a minor overdose of temazepam. At this point, it is essential to realise that the situation has changed. She is suffering major depression and requires treatment for it.
Genuineness
In comparison with other forms of psychotherapy, part of the role of the therapist in supportive psychotherapy is to be a model for the patient. Some minimal self-disclosure may even be appropriate. For example, you should give matter-of-fact answers to questions about where you are going on leave.You may give some acknowledgment that your life is not as perfect and ideal as he or she assumes.You may share a joke. On the other hand, it is quite inappropriate to discuss specific aspects of your life or your personal problems. This blurring of boundaries will only confuse the person over your role as a professional or a friend, as helper or helped (see Box 8-2).
Caveat
You do not take this further and begin ventilating your financial problems to the person.
Reassurance
The role of reassurance in therapy was discussed in Chapter 2. Reassurance is used more frequently in supportive psychotherapy than in most other forms of psychotherapy. Make sure that the reassuring statement is true and not merely a bland platitude (see Box 8-3).
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Caveat
A man with post-traumatic stress disorder complains of disturbing nightmares, often relating to his experience in Vietnam. He wakes around four times every night. Calculating that he nevertheless does get, on average, six hours sleep, you attempt to reassure him that his sleep is quite adequate. He fails to turn up for his next appointment.
Positive reframing
Even adverse events may have some positive aspect (see Box 8-4).
Caveat
This must be done sensitively. The statement you make must be true and should not be presented in a way that fails to acknowledge the reality of the losses that he suffers.
Explanation
Education of the person and the family about his or her illness is an essential component of treatment. People with severe disorders may have distorted perceptions of reality that adversely affect their judgement and behaviour. Clarification and explanation of the reality of a situation will help them meet challenges in more adaptive ways (see Box 8-5)
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Caveat
In telling a man that he suffers from early dementia, you do not offer unsolicited comments about the worst case outcomes. Nor do you argue strongly about the doubtful scientific efficacy of an inexpensive herbal treatment that he has faith in. Instead you are guided by his questioning (see also Chapter 7). The relatives and family may want more explicit information.
Advice
The use and misuse of advice were discussed in Chapter 6. Because of the persons limited coping skills, you will give advice more frequently in supportive psychotherapy than in other forms of psychotherapy.You will give advice about treatment of the illness and when and how to seek help; about every day problems such as budgeting, diet, good sleep habit and general self-care; and on social and interpersonal skillsfor example, being assertive or how to behave on social occasions (see Box 8-6).
Caveat
A woman has numerous complaints about her husband. Unless there are compelling reasons that she is at riskfor example, if he is violentit would be quite inappropriate for you to advise her to leave him. She must make such decisions herself.
Suggestion
Whereas advice involves giving a person explicit instructions about what to do in a particular situation, suggestion seeks to modify a persons behaviour by showing or withholding approval for their actions (see Box 8-7).
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Caveat
You take care not to collude with a young man as he laughs about his criminal activity.
Encouragement
By making encouraging statements about a persons actions you enhance his or her self-esteem, reduce his or her sense of ineffectiveness and promote further positive actions. Like reassurance, encouragement must be genuine and realistic if it is to be beneficial. It is important to stay alert to the possibility of change and progress. In view of the long-term nature of therapy and the low expectations of change, there is always the danger of missing or ignoring changes when they do occur (see Box 8-8).
Caveat
A young woman with borderline personality disorder who has not worked for five years intends to return to full-time work. You congratulate her on her initiative, but remind her that she might be better off trying some part-time work initially.
Caveat
You might understand the rage of a woman with borderline personality disorder as a reflection of her identification with her stepfather who abused her as a child. However, an interpretation along these lines is only likely to make her more upset.
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Interpreting defences
Though the interpretation of defences does not play a major role in supportive psychotherapy, there are times when it is useful to clarify how a person feels, and to discuss maladaptive ways that he or she responds to events. A useful technique is to ask a (man) to reflect back on how he reacted to a stressful event, after the event has passed and he is calmStrike while the iron is cold.1 Remember that the ego defences are deployed as a solution to problems. Removing them will, at least initially, lead to an increase in anxiety. In the face of unavoidable external stressors (for example, suffering a severe and chronic illness), some degree of denial is often adaptive (see Box 8-10).
Caveat
A 46-year-old woman with schizophrenia is upset and contemplating suicide after repeated arguments with her daughter. After her daughter is diagnosed and treated for post-natal depression, her distress subsides.You are then able to discuss and clarify the cause of her upset.
Caveat
A young man with chronic schizophrenia has little social contact outside his immediate family. He is, nevertheless, satisfied with this, as are his parents. While you remind him of the availability of various social activities, you do not press him too hard to engage in these.
Catharsis
Within a trusting therapeutic relationship, a person may be able to reveal events in their lives that they have been unable to discuss with anyone else (see Box 8-12).
Pine F. Supportive therapy, a psychoanalytic perspective. Psychiatric Annals 1986; 16: 526-529.
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Caveat
While respecting a young womans need to discuss her past sexual abuse, you nevertheless focus on helping her deal more effectively with her current problems.
Techniques of supportive psychotherapy include holding and containment, genuineness, reassurance, positive reframing, explanation, advice, suggestion, encouragement, monitoring the transference and countertransference, interpreting defences, improving social supports and allowing catharsis.
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Finally, there is a danger that in providing support, you may inadvertently perpetuate problems by maintaining equilibrium in a system that removes the impetus for a person to change. For example, regular visits to a therapist may prevent a person from doing something about his or her relationship problems.
Beware that therapy is not perpetuating problems by maintaining an equilibrium that removes the impetus for the person to change.
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Chapter 9
Behavioural treatments
Behavioural techniques derive from learning theory, which holds that both adaptive and maladaptive behaviours are learned through our interaction with the environment.Three models of learning are describedclassical conditioning, operant conditioning and social learning. A brief overview of behavioural treatments follows together with a case example.
Classical conditioning helps us understand the origin of phobias and the cues to anxiety and other affective states.
Operant conditioning
Operant conditioning explains how the frequency of a behaviour is increased or decreased.
Positive reinforcement
Skinner performed the following experiment. He placed a rat in a cage in which there was a lever that, when pressed, released a pellet of food. Initially, the rat only pushed the lever by chance. Then, as it learned the consequences of its action, the frequency at which it pushed the lever increased. Eventually, the rat was pushing the lever most of the time, even when it could not eat any more pellets. The pellet of food positively reinforced pushing the lever.
Negative reinforcement
Another experiment involved a rat receiving an electric shock whenever it went to one end of its cage. It quickly learnt to escape by running to the other end and staying there. In this case,
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relief from an aversive stimulus (the electric shock) is a negative reinforcer of the avoidance behaviour.
Punishment
Finally, the frequency of a particular behaviour can be reduced if an aversive stimulus or punishment follows the behaviour. In contrast to negative reinforcement, which increases the frequency of a behaviour (avoidance), punishment reduces its frequency. Examples of operant conditioning are shown in Box 9-2.
Operant conditioning explains how the frequency of a behaviour is increased or decreased. Box 9-2: Operant conditioning
Positive reinforcement Adam is the eight-year-old only son of a young professional couple. He sees little of them during the day, and they are usually too tired to spend much time with him when they get home. In response to the tantrums he has been having over the past month, both parents stop whatever they are doing and turn their attention to trying to placate him. The tantrums are becoming more frequent and lasting longer. Negative reinforcement Joyce had a panic attack at the supermarket three weeks ago. She ran out of the building, leaving her shopping behind, and she has not returned there since.The relief from anxiety negatively reinforces her avoidance behaviour.
Social learning
Bandura noted that we also learn by observing the behaviour of others and its consequences for them. For example, we learn to speak through imitation of our parents (see clinical example in Box 9-3).
Social learning explains how new behaviours can be learned by observing others. Box 9-3: Social learning
During treatment for her needle phobia,Tracey was able to observe her older sister having an injection without getting upset, and then being congratulated by her mother and the doctor.
Behavioural assessment
A behavioural assessment begins by operationalising the problem behaviourthat is, by describing the behaviour in a measurable and specific way. The second step is to explore what happened before and after the behaviour in order to identify any reinforcers. The third stage is to set the goals of treatment.
Behavioural assessment involves operationalising the target behaviour, clarifying its antecedents and consequents, and setting the goals of treatment.
Treatment
Some behavioural treatment techniques are listed below. 1. Counselling and problem solving (see Chapter 6 and Appendix 3) 2. Methods of arousal reduction These include controlled breathing, progressive muscular relaxation and self-hypnosis. They are described in the handouts for patients in Appendices 4, 5 and 6. 3. Daily activity schedules (see Appendix 7) By becoming more active, a person regains access to sources of positive reinforcement. Documenting pleasurable activities will correct the depressed persons perception that he or she is unable to gain any pleasure or satisfaction from life activities. A daily activity schedule can be used to document baseline functioning and the progress of treatment. It is often useful to suggest that patients incorporate some pleasurable activities, exercise, duties or chores, and social activities in their day.They can then document the actual activities and rate their responses to them using the schedule.
4. Exposure This involves the construction of a hierarchy of feared situations that the person then confronts in order from least fearful to most fearful. The person may first confront his or her fears in imagination before doing so in vivo. It is explained in the patient handout in Appendix 8. The person must stay in the feared situation: if she or he escapes, the relief from anxiety negatively reinforces the avoidance behaviour. Changes in the persons level of anxiety can be documented using the Subjective Units of Distress Scale (SUDS), (see Figure 9-1). The person can document how the level of anxiety falls when he or she stays in the situation (habituation), (see Figure 9-2). In order to maximise the efficacy of the treatment, patients should not be prescribed a benzodiazepine and should not take any safety devices with them such as mobile phones.The efficacy of the treatment depends on the person confronting his or her anxiety. By rating the peak level of anxiety experienced at each exposure, the person can also document the lessening of anxiety on each occasion (desensitisation), (see Figure 9-3). To promote desensitisation, the person should confront the feared situations regularly and frequently.
5. Exposure and response prevention This is the treatment of choice for the rituals of obsessive compulsive disorder. The person is asked to confront his or her fears (exposure) without performing the ritual (response prevention). Instead of using the ritual to decrease the anxiety, the person is asked to wait until his or her anxiety subsides through habituation. For example, a woman with obsessional fears of contamination may be asked to touch a door handle and then go about her usual activities without washing her hands.The person is then asked to work through a hierarchy of feared situations as described above. 6. Goal setting Goal setting is an important part of rehabilitation for chronic mental disorders. The first step is to engage the person in the process of change, discussing the pros and cons of staying the same or moving on.The next step is to identify problem areas and to reformulate these as needs: for example, a mans problem of being bored might be reformulated as, I need to become involved in some interesting activities. A list is then made of his strengths and other resources, including any specific talents (e.g. sporting or musical ability), people who will help, specific interests and past interests. Goals are then set that use the resources available to meet his needs. It is essential that the goals are realistic: if they are too difficult, the man may only be setting himself up for failure. On the other hand, they should be a challenge to him. A goal also needs to be formulated in a specific operationalised form. For example, rather than, Going to the movies, it could be, Going to see Titanic on Wednesday
night at the Hyperdome with Richard. Long-term goals need to be broken down into small steps. For example, the goal of returning to work might involve an occupational therapy assessment, referral to a job support agency, preparation of a resume, commencing work eight hours a day, then building up over a period of months. Progress should be monitored. People are praised for the goals they fully or partially attain. The assessment of progress determines the next step to be taken.
Outcome evaluation
The SPHERE-GP1 is a useful tool for assessing the outcomes of treatment (see Appendix 1).
Figure 9-1: Subjective units of distress scale (SUDS) plotted over time
Time
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Case example
Behavioural assessment operationalised account Jane presents to you after suffering a panic attack in a cinema. She begins by saying, I felt terrible. After further questioning, the operationalised account of what happened might be as follows: I was convinced that I was going to die. My heart was racing and I felt as if I was going to pass out. My fingers were tingling and I was gasping for air because I felt as if I was choking. A careful history and mental state examination excludes an additional diagnosis of depression.
Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T and Naismith S, Koschera A. The SPHERE Program: A training manual for treating depression and anxiety in general practice. Kogarah: Educational Health Solutions, 1998.
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Behavioural assessment antecedents and consequents of the behaviour Jane states that she has been very worried about various financial problems over the past six months. She has been ruminating over them and sometimes feels she will never get on top of them. Last Friday night, she went alone to see a movie, hoping to take her mind off her other worries. Twenty minutes into the movie, she had the panic attack. During the panic attack she felt that she had to get out of the theatre. Once outside, she felt better. She drove quickly home, buying a packet of cigarettes on the way. She smoked 10 of them and also drank three glasses of wine before going to bed. Behavioural assessment setting the goals of treatment Jane and her therapist settle on the following three goals: 1. to develop a plan to deal with her financial problems and to avoid maladaptive patterns of coping such as substance abuse 2. to learn to understand her anxiety symptoms and to control them 3. to be able to go to a movie on her own. Counselling and structured problem solving to deal with financial problems Counselling begins by clearly defining the problemher income versus her recurrent costs of living and her debts.Various options are explored: sending back the furniture that she is buying on lay-by; re-financing the loan to pay off her car (or selling the car); reducing her cigarette consumption; getting a part-time job in the evening. Having discussed the pros and cons of each possible solution, she chooses a plan of action. She writes down each step that she needs to take to implement the plan. The plan is then put into action. Later, its effectiveness is assessed and changes made where necessary. Treating the anxiety symptoms The therapist explains the nature of anxiety; its physical, psychological and behavioural manifestations; the fight and flight response; the relationship between anxiety and performance; and the causes of anxiety. She is then taught a method of arousal reduction (progressive muscular relaxation) and a breathing control technique. She is encouraged to practice these every day. As well as becoming more proficient in their use, the practice also enables her to experience what it feels like to be relaxed. The breathing control is also used to abort the onset of a panic attack. A cognitive approach is also used (see Chapter 10). She is asked to keep a diary of the dysfunctional thoughts that she has at times when she is feeling anxious. One entry from this diary is shown in Box 9-4.
Treating the avoidance behaviour Graded exposure is used to attain the third goalgoing to the cinema. First, Jane is taught about the theory of exposure. She is told that escaping from the cinema will only worsen the problem, because the avoidance is rewarded by a fall in anxiety.Therefore, she should only expose herself to situations that she is confident she can tolerate. If she stays in a feared situation, her anxiety level will fall. She can prove this by documenting her level of anxiety during exposure (habituation). Each time she enters a particular feared situation, she will experience a little less fear than she did the time before (desensitisation). She is asked to construct a hierarchy of feared situations from least feared to most feared. She rates the amount of anxiety that she expects to experience at each step on a scale from 0 to 100 where 0 means no anxiety and 100 is maximal anxiety (see Box 9-5).
Having assured herself that she will be able to manage the first step, she puts it into action. As part of her homework, she rates the peak anxiety level during each exposure. When this has fallen to around 50 per cent of the predicted anxiety level, she is ready to proceed to the next step. She will notice that her anxiety levels are lower on each repetition of a step. Documenting the outcomes of treatment The SPHERE1 instrument is used to assess her condition before, during and on completion of the treatment.
Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T, Naismith S, Koschera A. Treating Depression and Anxiety in General Practice:Training Manual. Kogarah: Educational Health Solutions, 1998.
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Chapter 10
Cognitive behavioural therapy (CBT)
This type of psychotherapy has proven effectiveness in the treatment of mild and moderate depression, panic disorder, agoraphobia, eating disorders and personality disorders. Its basic premise is that disturbed mood is caused by distorted, negative and maladaptive thinking. Disturbed mood, in turn, produces negative ways of thinking. CBT seeks to improve mood by identifying and challenging negative thoughts and replacing them with more realistic and adaptive ones. Useful references include the books by Hawton et al.1 and DeRubeis2. Self-help books include those by Tanner and Ball3, Burns4 and Beck and Greenberg5.
CBT is based on the premise that disturbed mood is caused by distorted, negative and maladaptive thinking.
The cognitive model described by Aaron Beck puts forward three concepts to explain the origin of depression: a) the cognitive triad b) schemas c) cognitive errors In reading this chapter, you may recognise a number of techniques that you already use. If so, I hope that the discussion helps you organise your interventions and encourages you to seek further training in CBT.
Background
The cognitive triad
The cognitive triad comprises three patterns of thinking that depressed people habitually use. First, a depressed man tends to have a negative view of himself, attributing any negative experiences he has to a fault within himself. Second, he tends to interpret his ongoing experiences in a negative way. He sees the world as making impossible demands upon him, obstacles are constantly being put in his path, and he is constantly being frustrated from realising his goals. Third, he has a negative view of the future, anticipating that his suffering will only worsen and that he will never attain his goals.
People with depression have negative views of themselves, the world and the future.
Hawton K, Salkovskis PM, Kirk J, Clark DM eds. Cognitive Behaviour Therapy for Psychiatric Problems: A Practical Guide. Oxford: Oxford University Press, 1989. 2 DeRubeis RJ, Beck AT. Cognitive Therapy. In: Dobson KS ed. Handbook of cognitive-behavioural therapies. New York: Guilford Press, 1988: 273-306 3 Tanner S, Ball J. Beating the Blues: a Self-Help Approach to Overcoming Depression Moorebank: Doubleday, 1989. 4 Burns DD. Feeling Good:The New Mood Therapy. Melbourne: Information Australia Group, 1980. 5 Beck AT, Greenberg RL. Coping with Depression. New York: Institute for Rational Living, 1974.
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Cognitive errors
People who are depressed make cognitive errors in processing information about their experience. Treatment involves identifying their automatic thoughts, recognising the logical errors in them and replacing them with rational responses to the events. Note, however, that CBT is not just about thinking positively, or eliminating unpleasant feelings altogether. Rather, it is about appraising events realistically. Some common cognitive errors are listed in Box 10-1.
CBT aims to uncover the cognitive errors that people make in evaluating events in their lives and to help them make more rational evaluations. Box 10-1: Common errors in thinking
Mind reading She thinks Im a fool. or They think Im a bore. Fortune telling Im sure to make a fool of myself. or Im sure to mess it up. Black and white thinking Things are seen as either all good or all bad. That is awful. or Ive totally messed it up. or Unlike me, he always gets things right. Labelling saying I am instead of I didIm an idiot. or Im a failure. instead of I did not win the competition. Overgeneralising saying always, never, no-one or everyoneI will never pass the exam. or Noone cares about me. Expecting too much of yourself saying should, must or have to, and so setting unrealistically high standards for yourselfI must do this perfectly. Refusing to accept praise He is only saying that because or It was only a fluke that Over-emphasising failure Now Ill never be able to do it. or Whats the point of trying again. or They will never accept me now. Personalisation blaming yourself for things over which you have no controlWhere did I go wrong that he could do that? Emotional reasoning I dont feel like doing it. or Maybe Ill feel like doing it tomorrow. Not considering the possibilities saying I cant. instead of How can I? Living in the past If only I had Focusing on the negative Because of one negative aspect of an event, you assume that it is all bad. He ignored me, so I must be a bore.
Treatment techniques
Introduction to therapy
Since the person is an active collaborator in cognitive behavioural treatments, he or she must first understand and be engaged in the process. He or she may wish to read one of the self-help texts mentioned above. A course of CBT usually requires at least eight weekly sessions, each of about 25 minutes duration.
Over the first week of treatment, it is useful to ask patients to make a record of their activities and their associated moods. They may rate their moods on a scale from 0 to 100, where 0 is the worst possible and 100 is the best. Simply identifying his or her moods may begin to give a person a sense of control over them.The record may later be used to provide evidence to correct cognitive distortions. For example, a man who says he is depressed all the time will realise that, in fact, he is only depressed at certain times of the week. The record also provides the starting point for increasing the range and scope of daily activities.
Early in therapy, patients are asked to make a record of their activities and the associated moods. Three-column technique
The next step is to ask people to record their automatic thoughts at times when they are experiencing unpleasant feelings. One way to do this is to ask them to draw three columns on a piece of paper. In the first column, they record the situation in which the unpleasant feeling arose. In the second column, they describe the feeling. In the third column, they record their automatic thoughts. People may often be unaware of their internal dialogue. The ability to reflect on and monitor their thoughts often provides, in itself, a sense of self-efficacy and emotional relief. The thoughts that need to be recorded are those that reflect on the personal meaning of the event for that individual (e.g. Im a failure.). A thought may be an inference about what the event means for the persons future (e.g. I will never get a job.). It may reflect on how other people will perceive them (e.g. Everybody will think that I am a failure.). Not all automatic thoughts are negative. Moreover, some negative thoughts are realistic and appropriate to the circumstances (e.g. a man feels guilty after swearing at his wife. He thinks, I should not have done that. I must apologise and do my best not to do it again.).Thoughts that are descriptions of mood should be recorded in the feelings column (e.g. I feel sad.).Thoughts that are descriptions of the event should be recorded in the situation column (e.g. I did not get the job.).What needs to be recorded are the actual thoughts the person had at the time, not a description of them (e.g. I will never be able to do this, rather than It was terrible. I didnt know what to say.). The handout in Appendix 9 will help explain this to patients.
Five-column technique
A next step is for patients to complete a daily record of dysfunctional thoughts.They are asked to draw five columns on a piece of paper. In the first column, they record the situation in which an unpleasant emotion was experienced. In the second column, they describe their mood and rate its intensity. In the third column, they record the automatic thoughts that accompany the mood. The strength of belief in these thoughts is rated on a scale of 0 to 100. In the fourth column, they note the cognitive distortion in the automatic thought and write a rational response to it. Patients should be reminded that some unpleasant thoughts are reasonable and contain no cognitive distortion.The aim is to appraise events accurately, not simply to think positively.The ability to correctly classify cognitive distortions is less important than the ability to recognise and challenge them. The following questions are helpful for finding rational responses to automatic thoughts: 1. What is the evidence for and against the belief? 2. What are alternative interpretations of the event or situation? 3. What are the real implications, if the belief is correct? 4. What would you say to a friend who said that? 5. What is the worst thing that could happen if it were true?
6. How likely is this worst case? 7. How would you deal with this worst case if it were true? 8. If the worst case came to pass, how would you feel about it tomorrow, next week, next month, in a year, in five years, in ten years? 9. All things considered, how likely is the thought to be true? Patients also rate the strength of their belief in the response. On completion of the exercise, they complete a repeat rating of their mood and their belief in the automatic thought. An example of a typical entry using the five-column technique is shown in Box 10-2.
The five-column technique is used to document unpleasant mood states, the situations in which they arise, the automatic thoughts that accompany them, the cognitive distortions implicit in the automatic thoughts, rational responses to them, and the outcome of the process. Box 10-2: The five-column technique
Situation While I was talking to a group of my friends, Tom got up and left without speaking to me. Mood Depressed and humiliated (rating of intensity of emotion: 70 per cent) Automatic thought He ignores me, so I must be boring. (rating of strength of belief: 75 per cent focusing on the negative) Rational response Although he doesnt seem to be interested, others are listening attentively, so I cannot be boring them. (rating of strength of belief: 80 per cent) Outcome (rating of depressed mood: 20 per cent) (rating of belief in automatic thought: 20 per cent)
It is important to distinguish between simple descriptions of how one feels (e.g. I feel guilty. or I feel ashamed. or I feel terrible.) from thoughts about the meaning of ones experiences (e.g. I feel guilty, because I should have been able to stop him drinking. or Because I did not win the race, I am a failure.). It is only the latter that can be challenged. Statements about how one feels are irrefutable. Descriptions of how one feels should be recorded in the mood column. Challenging the way people say they feel is unempathic and will only damage the therapeutic alliance.
Only thoughts about the meaning of events can be questioned; descriptions of how one feels cannot be refuted.
Later in therapy, the patient may use a simplified version, the two-column technique, which focuses on the automatic thoughts and rational responses. Box 10-3 demonstrates this twocolumn technique and contains examples of the cognitive distortions.
What if that did happen? What would this mean to me if it were true? What is so bad about that? What do I mean by that?
The vertical arrow technique is used to elucidate underlying assumptions that may predispose a person to depression.
A useful tool for uncovering these schemata is the Dysfunctional Attitudes Schedule1. Some of the dysfunctional attitudes that may predispose to depression are shown in Table 10-1.
Burns2 suggests a number of variants of this approach in challenging some underlying assumptions: 1. List the advantages and disadvantages of the assumptions. 2. Compare the predicted satisfaction gained from a particular activity with the actual satisfaction recorded after completing the activity. For example, a woman with underlying assumptions about the need for love and approval may discover that she gains just as much satisfaction from solitary activities as from activities that involve others. The man who is addicted to achievement may find that he gets a lot of enjoyment from activities outside work. 3. For the perfectionist, Burns3 suggests recording satisfaction with an activity together with a measure of how effectively (percentage of perfection) it was done. people often find that the two are not as closely related as they had assumed.
Weissman AN. The dysfunctional attitudes scale: a validation study. Dissertation Abstracts International 1979; 40: 1389-1390. 2 Burns DD. Feeling good:The New Mood Therapy . Melbourne: Information Australia Group, 1980. 3 ibid.
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The boss complimented me, but he probably just felt sorry for me. I didnt vacuum the floor today. Therefore, the house is filthy.
He should be more considerate. I did not get into the A Team. I am a failure. If only I had worked harder, I would now have a better job. I cant play tennis. My son has been found smoking marijuana. Therefore, I am a failure as a mother.
Behavioural techniques
An inability to act is common among depressed people. Since they are unable to solve their problems, their difficulties tend to escalate and they lose access to sources of positive reinforcement. A number of techniques can be used to assist problem solving and to help people become more active: 1. Counselling and structured problem solving (see Chapter 6) 2. Daily activity schedule (see Appendix 7) Plan each days activities hour by hour. The person begins each day by reviewing the activities he or she actually undertook the day before. The advantage of having a schedule is that it removes the need to make a decision about what to do on the day. If the person fails to implement the schedule, the reasons can be explored using the cognitive techniques described above.
3. List the advantages and disadvantages of a particular action, or of doing nothing. 4. Test negative hypotheses. For example, a man who believes that he can only get pleasure doing things with other people could test this by listing the activities for the day, rating the pleasure expected to be experienced doing each, and then reviewing the actual pleasure experienced on completion of each activity. Contrary to expectations, people often find that they got as much, if not more, pleasure from solitary activities than from doing things with others. 5. Break complex tasks down into a series of steps. 6. For people who have difficulty motivating themselves to act, it may be useful to list the thoughts that oppose action and then rebut them with thoughts that promote action. 7. Others are often telling people who are unable to act that they must do something. This may only exacerbate the problem, because being told what to do often removes the pleasure in doing it. People often react to nagging by doing nothing. They may have to learn to do things in spite of the fact that this may please those who are nagging them.
People sometimes have to do something, in spite of the fact that it is what other people are nagging them to do.
Chapter 11
Interpersonal psychotherapy (IPT)
This form of therapy was originally developed in the USA by Gerald Klerman and Myrna Weissman for the acute treatment of outpatients with non-psychotic depression1, 2. It has also been used in the maintenance treatment of depression and in the treatment of a number of specific populations of depressed peopleadolescents, older people, HIV positive patients and people with dysthymia,3 bipolar disorder4 and bulimia nervosa.
Background
The principal assumption of IPT is that a persons mood, and events in his or her interpersonal world, are interdependent. Interpersonal eventsboth adverse and favourablecan lead to depressive symptoms, and depression may, in turn, impair a persons interpersonal functioning. By actively intervening to improve a persons interpersonal functioning, his or her mood will also improve.The focus of treatment is on interpersonal problems in one of four areas: grief, role disputes, role transitions or interpersonal deficits.
An assumption of interpersonal psychotherapy is that by improving a persons interpersonal functioning, his or her mood will also improve. General characteristics
The therapy is time-limited. In the original descriptions by Klerman and Weissman, it is spread over 1216 weekly sessions each of 50 minutes duration. In this form, it is probably not suitable for use in general practice. However, a shorter version comprising six half-hour sessions interpersonal counselling (IPC)has been shown to be effective in primary care populations5.
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for a discussion of the relative indications for IPT versus CBT). While dynamic psychotherapy may attempt to change a persons personality, IPT does not set this as a goal. IPT, nevertheless, recognises the influence of personality on the outcome of treatment, on the patient/therapist relationship and on interpersonal functioning.
Therapy concentrates on one (or at most two) of the four problem areas: grief, role dispute, role transition or interpersonal deficits.
Hamilton M. Development of a rating scale for primary depressive illness. British Journal of Clinical Psychology 1967; 6:278-296.
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People often present with problems in several of the key problem areas. Focus on the one that best encapsulates the event that precipitated the depression. Present your formulation to the person (see example in Box 11-1) and seek agreement on the focus of therapy.
Explain the concepts and process of IPT. He or she may wish to buy the patients guide to IPT1 Tell a (female) patient that IPT focuses on here and now issues, and that she will need to discuss important events in her interpersonal world and describe her feelings about these. Reach an agreement with her about the nature of the therapy and the number, frequency and duration of the sessions.
People undergoing IPT need to understand and agree that therapy will focus primarily on here and now issuesin particular, their relationships with significant people in their livesand that they will be expected to discuss these relationships and their feelings about them. Middle phase (sessions 412)
The middle sessions focus on the key interpersonal problem area. You should generally begin sessions by asking an open-ended question about the past week and any significant events, such as How have you been since the last session? What has happened? Ask the person to describe the events in detail, including the way he or she felt. Make links between the events and the persons mood. In discussing an interpersonal conflict, it is often useful to ask, What did you want? Ask a (female) patient to consider other ways that she could have dealt with the situation. Explore the positive and negative consequences of the different possibilities. She may benefit from rehearsing more effective ways of coping. Complex tasks may be broken down into a series of more manageable steps. Easy tasks are often best performed before more difficult ones. Grief The aim is to facilitate the mourning process, and to help the person move on and establish new relationships and interests (see also Chapter 7). Grief is abnormal when symptoms are excessively severe or persistent, or when they fail to appear. In the latter case, the person may experience symptoms later, for example, on the anniversary of the death.
The goals of grief work are to facilitate the mourning process and to help the person move on and develop new relationships and interests.
Review the depressive symptoms and their relationship to the death.The person with unresolved grief often idealises the relationship with the deceased, while refusing to acknowledge anything positive about events following the bereavement. Ask the person to describe both positive and negative aspects of the relationship, and of the future without the deceasedWhat do you miss?
Weissman MM. Mastering depression: A Patients Guide to Interpersonal Psychotherapy. Albany, New York: Graywind Publications Incorporated, 1995.
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What dont you miss? It is particularly important for the person to be able to acknowledge negative aspects of the past relationship and to feel free to experience and express negative affects associated with these. The process of mourning may be facilitated by having the person go through the belongings of the deceased and other mementos such as photographs. Ask the person to describe in detail the events surrounding the death. Exactly what was he or she doing before, during and after the death? How did he or she feel? Encourage the person to acknowledge both good and bad affects. For example, a man may feel guilty that he could do nothing to save the person, or that he was not present at the moment of death. Was he able to discuss his feelings after the funeral? Did he express his grief or did he cover it over? Encourage the person to move on. Ask, Where do you go from here? It may be relevant to explore the implications of becoming a professional mournerpeople sometimes believe that if they stop grieving, the person will be forgotten. Promote the formation of new relationships and participation in new activities. Role dispute The aim is to clarify the nature of the dispute and to modify expectations and faulty communication in order to bring about a more adaptive resolution of it. The most appropriate action to take will depend on the stage of the dispute. If there is open conflict, the participants will need to calm down before the problems can be renegotiated. If the dispute has reached an impasse (i.e. if communication about the problem has ceased, while an atmosphere of tension and suppressed hostility remains), the level of overt conflict will rise as the issue is brought out into the open. In some cases, the conflict may be irreconcilable with the only solution being to dissolve the relationship. Here, the role of the therapist is to facilitate the mourning process and then to encourage the formation of new relationships.
The source of role disputes is often found in non-reciprocal expectations of the two protagonists.
Depressed people often blame themselves for things over which they have no control, or for failing to meet unreasonable expectations of others. Clarify these issues and, where applicable, normalise forbidden affects: If someone treats you like that, you have a right to feel angry. You are entitled to expect things to change. The person may benefit from rehearsing more assertive behaviour. It may be useful to ask the partner in a marital dispute to attend some of the sessions. Role transitions The aims are to mourn the loss of the old role, to recognise positive aspects of the new role and to restore self-esteem by developing a sense of mastery over the demands of the new role. Begin by reviewing the depressive symptoms and linking them to the change in role. Giving up an old role is a loss, which the person needs to mourn. Encourage the person to talk about the loss and to express feelings associated with it, including negative feelings such as anger, frustration and guilt. Review the positive and negative aspects of the new role. Even adverse events present
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some positive opportunities. Encourage the person to take advantage of these opportunities. Correct false assumptions that he or she has about the new role. Teach structured problem solving to deal with the practical consequences of the role transition. Review opportunities that the person has for making new social relationships. Interpersonal deficits The aims in treating people with these problems are to reduce their loneliness and social isolation, and to encourage the formation of new relationships. Since these problems are often difficult and long standing, the goals of therapy are modestto start work on alleviating them, rather than completely resolving them. Owing to the absence of significant current relationships, therapy focuses on past relationships, the therapeutic relationship and forming new relationships.
People whose primary problems are interpersonal deficits are encouraged to reduce their social isolation and to form new relationships.
Review the depressive symptoms and link them to the persons social isolation. Clarify the patterns of significant past relationships and note any recurring problems. Ask the person to consider both positive and negative aspects of these relationships. Use the therapeutic relationship as a model of how the person relates to othersthat is, actively discuss the transference. Ask a (female) patient to tell you if there is something you do that upsets her. Ask her to articulate her feelings and discuss her concerns. Use the techniques of communication analysis and role-playing discussed below. Encourage the person to put his or her newly learned skills into practice by getting in touch with old friends, going out with new friends and attending social functions.
Frank E, Kupfer DJ, Perel JM Cornes C, Jarrett DB, Mallinger AG, Thase ME, McEachren, AB, Grochocinski VJ. Three-year outcomes for maintenance therapies in recurrent depression. Archives of General Psychiatry 1990; 47:1093-1099.
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Techniques of therapy
Klerman and Weissman1 describe the following techniques as applicable (though not unique) to IPT.
Clarification
You might ask a man to repeat what he just said, or paraphrase his statement and check if that is what he meant.You may wish to clarify how a person feltYou felt very frustrated? Point out the logical consequences of what the person has said. Draw attention to apparent contradictions to clarify what the person means or feelsIt is interesting that in the last session you said you had never enjoyed his company, but today you say you did have a good time together last weekend. Use cognitive techniques to identify and challenge irrational automatic thoughts and underlying assumptions (see also Chapter 10).
Communication analysis
The goal is to identify communication failures and to learn new and more effective skills. Sometimes, conflicts arise simply through a lack of communication. Identify and modify the following unhelpful communication styles: using ambiguous non-verbal communications, such as sulking, remaining silent or self-harming; assuming that others know how one thinks or feels without being told; not checking the veracity of a ones assumptions (He thinks Im a fool); or being unable to assert oneself or criticise another person because of exaggerated fears of the consequences.
Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York: Basic Books, 1984.
Interpersonal psychotherapy (IPT)
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interpersonal deficits who have few other significant relationships. Ask patients to tell you if you do something that upsets them.They then have the opportunity to rehearse being more assertive and you have the opportunity to correct faulty assumptions that they make.
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Training in IPT
You will need to read the text by Klerman and Weissman1. The Hamilton Depression Rating Scale (HAM-D) is the instrument that has been used to assess outcome in the major trials of the efficacy of IPT2.
Those wishing to practise IPT should read the text by Klerman and Weissman, and video or audiotape at least one course of therapy.
To gain competence in IPT, you need to complete three supervised cases that are certified by an IPT expert. It is useful to video or audiotape at least one course of treatment and discuss this, session by session, within a group of your peers who are interested in IPT. Like the techniques of CBT, there are probably several IPT techniques that you already use. I hope that this discussion will encourage you to embark on further training.
Klerman GL, Weissman MM, Rounsaville BJ, Chevron ES. Interpersonal Psychotherapy of Depression. New York: Basic Books, 1984. 2 Hamilton M. Development of a rating scale for primary depressive illness. British Journal of Clinical Psychology 1967; 6 :278-296.
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Chapter 12
Dynamically informed therapy
Psychodynamic treatments range across a broad spectrum from expressive therapies, including psychoanalysis, which aims to produce personality change, to supportive therapies that aim to improve coping by bolstering a persons existing personality structures, including his or her habitual coping styles and defences (see Chapter 8). The three main theoretical schools are egopsychology (Freud et al.), object relations (Klein, Mahler et al.) and self-psychology (Kohut, Kernberg et al.). In this chapter, I discuss eight dimensions of the psychodynamic assessment of personality that are useful in formulating the psychological components of patients problems. I also describe two psychodynamic interventions that can be used in general practiceempathic responses and interpretation. I refer readers to Gabbards book for a detailed description of the different psychodynamic theories and their application in therapy1.
Impulse control
An impaired ability to delay the gratification of drives and desires may be manifest in substance abuse, sexual promiscuity, paraphilias, binge-eating or a pattern of repeated violent or selfharming behaviour. The characteristic defence is acting out (see page 102).
The characteristic defence of people with impaired impulse control is acting out.
Impaired impulse control is a feature of the Cluster B personality disordersborderline, antisocial and histrionic (see Chapter 23). People with psychotic illnesses or depression may also exhibit impaired impulse control. Biological factors that predispose to poor impulse control include genetic factors, brain damage (especially to the frontal lobes), dementia, delirium, and the abuse of alcohol and stimulants. Abused children who have been the victims of adults with poor impulse control may be at risk of developing problems with impulse control themselves. Some examples are shown in Box 12-1.
Psychosis
A man with schizophrenia sets fires in response to commands of the voices that he hears.
Depression
A depressed woman with no previous criminal history shoplifts some relatively inexpensive articles that she could easily have afforded to buy. She cannot explain why she did it, but expresses how ashamed she feels and her belief that she should be punished like any other criminal.
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Self-esteem
A persons perception of him or herself as a good person, worthy of the affection of others, is impaired in depression. In Mourning and Melancholia, Freud described a loss of self-esteem as one of the principal features of depression and one that distinguishes it from normal mourning1. People with personality disorders are predisposed to depression because of their low self-esteem. In particular, child abuse may damage self-esteem (see Box 12-2).
People with a low self-esteem are vulnerable to depression. Box 12-2: Examples of low self-esteem
Dependent personality disorder
A woman with a dependent personality disorder has a low self-esteem that is evident in her inability to make decisions for herself. She has suffered recurrent bouts of depression.
Shame is the emotion that we experience when we fail to live up to the image we have of how we should behave. Guilt is the emotion that we experience when we do something wrong that hurts another person.
Freud S. Mourning and Melancholia in The Pelican Freud Library,Volume 11: On meta psychology: the theory of psychoanalysis. Ed. Angela Richards. Ringwood,Victoria, Penguin, 1984.
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Quality of relationships
The ability of a person to form enduring close relationships with others, including intimate relationships, is an important measure of his or her psychological health.The quality of a persons relationships is an important factor in the prognosis of his or her mental disorder. The patterns of relationships formed throughout life often reflect early bonds with parents and siblings. These recurring patterns become evident during therapy in the transference and countertransference.
The patterns of relationships formed throughout life often reflect early bonds with caregivers.
Bowlby writes that the presence of strong and stable attachments in early childhood permits the child to begin to explore the world from a secure base and, in adulthood, to form intimate relationships, and to be resilient in the face of stressful life-events. By contrast, children who form anxious attachments are less well adapted and, in adulthood, have difficulty forming intimate relationships, are vulnerable in the face of stressful life-events, and are prone to depression and anxiety.
Defence mechanisms
Freud postulated that unconscious sexual and aggressive drives are prevented from reaching consciousness by unconscious ego defence mechanisms. The primary defences are repression and denial. Repression is the shutting out from consciousness of an unacceptable drive, wish or other aspect of internal reality. Denial is the disavowal of unacceptable or threatening aspects of external reality. Examples of repression and denial are given in Box 12-4.
The maturity of defences that a person habitually uses is an indicator of his or her psychological health.
Vaillant GE. Theoretical hierarchy of adaptive ego mechanisms. Archives of General Psychiatry 1971; 24: 107-116.
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Narcissistic defences
These are features of psychotic illnesses, but may also be evident in children before the age of five and in adult dreams and fantasy. They include delusional projection, psychotic denial and distortion.
Immature defences
These may be seen in normal children and young people between the ages of three and 16. Adults with personality disorders also use these defences. Projection the attribution of ones own unacknowledged feelings to others. Its use is a feature of paranoid personality disorder. Passive-aggression the turning against oneself of hostile feelings towards others by procrastinating, forgetting, being late for appointments, doing things deliberately slowly or clowning around instead of completing a task Acting out acting on an impulse without reflection in order to avoid experiencing a painful affect and the thought that accompanies it
Neurotic defences
Displacement shifting an unacceptable feeling about an important and powerful person in ones life on to someone less powerful Intellectualisation the excessive use of intellectual processes as a means of avoiding the experience of distressing feelings Reaction formation warding off an unconscious wish or impulse by adopting a characteristic trait that is diametrically opposed to it Dissociation the compartmentalisation of ones identity to avoid emotional distress (see also Chapter 21). A person may be amnesic for a traumatic event, but suffer flashbacks of it. Counterphobic behaviour may defend against feelings of inadequacy and fear. An actor is able to dissociate into the character that he portrays. Members of a fundamentalist church
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dissociate when they speak in tongues. Like all of the secondary defences, dissociation is preceded by repression or denial. It is distinguished from repression by being a vertical split in which mental contents are stored in a parallel consciousness; in repression, there is a horizontal split with material being transferred to the unconscious.
Mature defences
These include humour, anticipation, sublimation and altruism.
Passive-aggression
You are seeing a couple for marital counselling.The husband arrives 15 minutes late for the appointment. His wife says that this is typical of himhe is never on time. He gave up his middle management position in the public service three years ago to enrol in post-graduate studies in philosophy. He receives a small allowance from the government, but his wife has been largely responsible for supporting the family over this period. He is having difficulty completing his thesis and has already had two extensions of the date it is due. Last weekend, he forgot that his wifes parents were coming to dinner and arrived home just as they were leaving having spent the evening in the library working with newfound enthusiasm on the thesis.
Acting out
A young woman with borderline personality disorder cuts herself with a razor blade.When asked what she was thinking about at the time, she states that she cannot remember. Nor can she describe how she was feeling; and she cannot identify any precipitant for her action.
Displacement
A man is under financial pressure having to support his wife and five children and pay off a home mortgage from the living he makes as a salesman. His boss is constantly reminding him of the need to meet the monthly sales targetsa failure to do so is met by veiled threats about job security.The mans wife is upset and embarrassed by his increasingly extreme views about Aborigines and migrants that he angrily propounds whenever they have friends over.
Intellectualisation
A woman consults you four months after the death of her 15-year-old son from leukaemia. She is exasperated because her husband is spending more and more of his time researching alternative medical treatments for cancer. He spends most evenings scanning the Internet for new information. She feels she can discuss nothing else with him, including their sons death.
Reaction formation
A young woman presents to you depressed. She is married with three children, aged one, three, and five years. She has always appeared anxious to do the best for her children. She says that her husband and mother both say that she spoils them, but she cannot help it. She brings the children to see you frequently, often with relatively minor problems. Despite having some family supports, she has never used a baby-sitter, always insisting she should look after the children herself. In the context of a strong therapeutic relationship with you, she begins to be able to recognise and accept as normal, her occasional frustration and anger at the demands placed upon her by her children. She may later begin to be able to deal with her feelings by using more mature defences, such as humour and sublimation.
Dissociation
A young woman is amnesic for a vehicle accident in which her boyfriend was killed. Despite suffering no serious injury herself in the accident, she continues to suffer frightening nightmares, she feels constantly tense and irritable, and she has withdrawn from most of her usual social activities.
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Developmental stages
A number of writers have described sequences of stages in human psychological development. Unlike the psychosexual stages described by Freud that focus on early development, the stages in psychosocial development described by Erikson cover the whole of the life cycle. Each stage is characterised by a core conflict (see Table 12-1)1. Coping with normal developmental tasks is stressful and can precipitate mental health problems (Box 12-6).
Coping with normal developmental tasks is stressful and can precipitate mental health problems. Table 12-1. Eight Ages of Man2
Age 01 13 36 612 1218 1830 3060 60 > Core conflict trust vs. mistrust autonomy vs. shame and doubt initiative vs. guilt industry vs. inferiority identity vs. role diffusion intimacy vs. isolation generativity vs. stagnation ego-integrity vs. despair
Regression
Regression is a common sign of mental distress, especially in children. People who have not resolved early developmental conflicts are prone to regression when under stress. This is particularly likely to occur when a stressor reactivates earlier conflicts (see Box 12-7).
1 2
Erikson EH. Childhood and Society, 2nd Edition. New York:VW Norton, 1963. ibid.
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Regression is a common sign of mental distress, especially in children and young people. Box 12-7: Example of regression
A 24-year-old man consults you about a number of current problems, but his main need seems to be to talk about himself and for you to listen. If you attempt to interrupt, he quickly becomes anxious and agitated, speaking more quickly, often simply ignoring what you have to say. He seems driven to complete what he wishes to say and sometimes brings a list of things he needs to tell you. Just as the session is about to finish he tells you how angry he was with another doctor who, he says, was always rigid about the time, throwing him out when time was up. You know from his background that, as a child, his father would often come home drunk and, after arguing with his wife, come to the boys room and insist that he get out of bed and listen as he recounted the problems and frustrations of his day. Comment: At an age when he needed support and nurture from his parents, he instead had to provide his father with support and sympathy. Ten years later, he is still seeking the care that he missed as a child. In the transference, he becomes like his father, and you experience, in the counter-transference, how he felt as a child.
Repetition compulsion
The preceding example illustrates how patterns of early attachments often tend to repeat themselves throughout a persons life, even though these patterns may have been painful or even abusive. It seems that any attachment is better than none (see Box 12-8).
Patterns of early attachments often repeat themselves throughout a persons life even though these patterns may have been painful or even abusive. Box 12-8: Example of repetition compulsion
You see a young man whose wife has recently taken out a restraining order to prevent him visiting her. She recently left him, together with their two young children. On describing his background, he tells you that he hated his father. His earliest memories are of his father coming home drunk and verbally and physically abusing his wife while the children hid under their beds, knowing that they might be the next victims of his rage. Comment: Despite suffering at the hands of his father as a child, he has nevertheless identified with him (identification with the aggressor) and now acts like him.
Empathy
Empathy is experiencing ourselves what it is like to be in the position of another person. We can feel the sadness of someone who tells of the death of a loved one. We can experience the anger of someone who has been frustrated and deceived. As well as being a tool for understanding patients, empathic responses strengthen the therapeutic alliance and can, themselves, produce change (see Box 12-9).
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Empathic responses strengthen the therapeutic alliance and can, themselves, produce change. Box 12-9: Empathic response
A 63-year-old woman becomes depressed six months after her husbands death from complications of alcoholic liver disease. You know that she had to tolerate both verbal and physical abuse over the years of their marriage. After he died, others reported that she coped very well. She reports that she has never cried over his death. You can empathise with the ambivalent feelings she has towards her husband. These make it difficult for her to mourn his death. In the context of a trusting relationship with you, she begins to acknowledge her anger towards him, as well as her guilt that she had sometimes wished he were dead. Acknowledging these negative affects within the therapeutic alliance will allow her to experience her sadness and to mourn her loss. (If her symptoms of depression persist, she may also require treatment with antidepressants).
Repeated empathic failures by caretakers during infancy and early childhood are thought to predispose to problems in self-esteem, and in ones sense of identity and personal coherence in adulthood. A consequence of the low self-regard of people with narcissistic personalities is an extreme sensitivity to any minor sleight or perceived insult. Empathic responses during therapy can, over a period of time, ameliorate these traits (see Box 12-10).
Repeated empathic failures in infancy are thought to contribute to the development of narcissistic personality disorder. Box 12-10: Example of empathic failures in childhood
A 28-year-old man is furious with you because you are late for his appointment.You feel angry at such entitled and demanding behaviour, but recognising these feelings, you take care not to act it out.When he settles down, you acknowledge his feeling of hurt and explain why you were running late. It might then be appropriate to make an interpretation. For example, You get very upset when people do not meet their commitments to you.
Be careful that by being empathic you do not collude with the persons problems and make them worse. Reflect on the transference and countertransference in order to avoid pseudoempathic responses (see Box 12-11).
Be careful that by empathising with a persons experience you do not reinforce his or her maladaptive behaviour patterns. Interpretation
Interpretation covers a wide range of interventions. It may simply involve a clarification of what a person says or how that person feels. For example, when an elderly man says that his daughter failed to visit him over the weekend, you might say, You would have felt let down...angry with her. You might interpret a defence. For example, when a woman whose mother recently died talks at length about current problems with the local council, and the weather, you might interpret her denial by saying, It is too painful for you to talk about your mothers death. Defence mechanisms are deployed in order to solve some intrapsychic conflict.The equilibrium that they provide may be the most adaptive solution to a persons problems at that time. For
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example, the numbing that is evident in people who have recently been exposed to a severe trauma is, at least initially, adaptive because it prevents the person from being overwhelmed.Two years after the event, however, such denial is not adaptive and may lead to severe handicap withdrawal from social supports and a loss of access to pleasurable activities. It is a matter of judgment when to interpret a defence. In the midst of a crisis it is often better to bolster a persons defences, but once the crisis is over it may be helpful to interpret and try to change them. Removing a defence will always cause some anxiety. It should be remembered that the development of psychotic symptoms is one of the recognised complications of psychoanalysis. You might make an interpretation within the transference (see Box 12-12)
For the most part, the interpretations that you make in general practice will be clarifications. Making interpretations at deeper levels can be problematic. Even though an interpretation may be correct, it is not necessarily helpful and may even be damaging. For example, a 14-yearold boy who lives with his mother and stepfather is having problems at school. The following might be true, but it would certainly be inappropriateYou are displacing the anger with your oedipal rival on to your teachers. As a rule, the patient makes the most effective interpretations him or herself, with you providing the trusting and empathic relationship that allows such selfreflection.
In general practice, the commonest interpretations are clarifications. Interpretations at deeper levels can be problematic.
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The correct timing of an interpretation is vital, and your empathy with a patient will be a good guide. For example, in the case of the old man mentioned previously, you might realise that he was neither sad nor angry that his daughter did not visit him. He was pleased, because it meant he could go fishing with the man next door. Reflect on the countertransference and ensure that you are not acting out when making an interpretation. For example, a young woman with borderline personality disorder may evoke in you intense feelings of anger. If you do not recognise this, you may act out by making a cruel statement to her masked as an interpretation. Finally, there is always the danger of wanting to be clever. The elegance of an insight can sometimes tempt us to make an interpretation that is either wrong or mistimed. As a rule, it is better to say nothingto listen and clarify, rather than risk making an interpretation that may be perceived by the patient as unempathic, demeaning or even insulting.
Training
The aim of this chapter was to acquaint you with some of the principles of dynamic psychotherapy that may help improve your understanding of patients and deepen your formulations of their problems. If you wish to perform short-term dynamic psychotherapy, you should first undergo a period of training and supervision.
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Chapter 13
Pharmacological treatments
This chapter contains brief descriptions of the classes of drugs that are most commonly used in the treatment of mental disorders. The recommended doses are for physically healthy adults of average weight. Adjustments need to be made for elderly people, children, young people and those with physical illnesses. Drug treatments for mental disorders are changing rapidly. I therefore, recommend that you obtain each new edition of Therapeutic Guidelines, as it becomes available1.
General practitioners are advised to obtain a copy of each new edition of Therapeutic Guidelines as it becomes available.2
Antipsychotics
Traditional antipsychotics have been used in the treatment of psychosis since the 1950s. Recently, five new drugs have become available in Australiaclozapine, risperidone, quetiapine, olanzapine and amisulpride. These have different mechanisms of action, side effect profiles and therapeutic responses from conventional antipsychotics. See also Chapter 22 for practical tips on the prescription of these drugs.
Traditional antipsychotics
These drugs are thought to exert their therapeutic effects through the blockade of D2 dopamine receptors in mesolimbic and mesocortical systems. The main indication is the treatment of positive symptoms of psychosis (i.e. hallucinations, delusions and formal thought disorder) and the prevention of relapse in schizophrenia. They are less effective and slower to act in the alleviation of negative symptoms. In fact, they may worsen negative symptoms when used in high doses. They are also used in the treatment of other acutely disturbed people, for example, the delirious patient. There is no evidence that any one traditional antipsychotic is more effective than another. The differences are in the side effect profiles. In general, low potency drugs, such as chlorpromazine, cause more sedation and anticholinergic side effects, but only moderate extrapyramidal side effects, while high potency compounds, such as fluphenazine, trifluoperazine, haloperidol and thiothixene, have more extrapyramidal effects, but cause less sedation and fewer anticholinergic effects.
Low potency antipsychotics cause more sedation and anticholinergic side effects. High potency drugs cause more extrapyramidal side effects.
Depot preparations of fluphenazine (Modecate), haloperidol (Haldol), flupenthixol (Fluanxol), risperidone (Risperdal Consta) and zuclopenthixol (Clopixol) may be prescribed when adherence to oral medication is in doubt. Note that the depot medication is zuclopenthixol decanoate (Clopixol Depot). Zuclopenthixol acetate (Clopixol Acuphase) is used for the management of psychiatric emergencies and can cause marked sedation for around three days.
The Writing Group. Therapeutic Guidelines: Psychotropic Version 4, 2000. North Melbourne, Therapeutic Guidelines Ltd: 2000 2 ibid.
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Recommended doses of antipsychotics are lower than those used in the past. Doses above 15mg equivalent of haloperidol have no additional antipsychotic effect, but certainly increase the incidence of adverse effects. Antipsychotics take at least two weeks to begin to produce their therapeutic effect. In the treatment of first episodes of psychosis, they may take as long as 11 weeks to act. Therefore, it is important to be patient and not increase doses prematurely in the early phases of treatment.
Doses above 15mg equivalent of haloperidol produce more side effects, but no additional antipsychotic effect.
In acute psychosis, control of disturbed behaviour can be gained through adjunctive treatment with a benzodiazepine. Antipsychotics are usually continued for at least 12 months following a first episode of psychosis. If the person remains symptom free, the dose may then be gradually lowered and then ceased. It is wise to follow up patients for at least 12 months after ceasing an antipsychotic. Use anticholinergics to avoid dystonic reactions early in treatment or when the dose changes. Young men are particularly prone to suffering dystonic reactions, especially when administered potent antipsychotics. Once a steady dose has been established, the anticholinergic can usually be withdrawn. Anticholinergics have significant side effects of their owndry mouth, constipation, blurred vision, worsening of glaucoma, urinary obstruction and confusion. In the elderly, they can cause delirium. Moreover, with the exception of Parkinsonism, they are of limited value in treating the other extra-pyramidal syndromes. For persistent extrapyramidal symptoms, consider dose reduction or switching to one of the newer antipsychotics.
Once a steady dose of antipsychotic has been established, anticholinergic agents can usually be withdrawn.
Adverse effects 1. Extrapyramidal effects These are caused by dopamine blockade in nigrostriatal pathways. a) Acute dystonia involves muscular spasm of the extra-ocular muscles (oculogyric crisis), the neck, trunk or hands.Young males are particularly at risk, especially early in treatment. Laryngeal dystonia can be fatal. Always warn patients and their carers about dystonic reactions. Laryngeal dystonia can be accompanied by a feeling of tongue swelling. Be careful not to mistake this for an allergic reaction. Consider the use of an anticholinergic agent, especially when commencing treatment with one of the potent antipsychotics. b) Akathisia is a feeling of agitation usually accompanied by restless legs. It is a particularly unpleasant side effect. Since people often do not recognise that it is a drug side effect, you should inquire about it. It is generally less responsive to anticholinergic treatment than dystonias and Parkinsonian side effects. Treat it by reducing the dose or by changing to one of the newer antipsychotics. Diazepam and propranolol may help some people cope with this side effect.
Akathisia tends to respond poorly to anticholinergics. Treat it by reducing the antipsychotic dose or changing to one of the newer atypical agents.
c) Parkinsonian side effects include rigidity, bradykinesia and a fine tremor. On examination, cogwheeling may be present. Parkinsonian side effects may be complicated by falls, especially in the elderly. They may be mistaken for signs of a depressive syndrome. Anticholinergics may reduce acute Parkinsonian symptoms, but dose reduction or changing to a newer antipsychotic are better long-term strategies.
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d) Tardive Dyskinesia is a potentially permanent adverse effect of antipsychotics involving abnormal choreoathetoid movements, especially of the tongue, mouth, lips and jaw. It may also affect muscles of the limbs and trunk.Tardive Dystonia involves mass involuntary contractions of muscles of the tongue, face, neck and back. The risk of developing these side effects increases with increasing exposure to traditional antipsychotics. However, they can occur after only limited exposure. The elderly (especially older women) and people with brain damage are at higher risk of developing the tardive syndromes. Remember that antipsychotics, while causing these adverse effects, also suppress their manifestations. As a consequence, they may first become evident after dose reduction. Since there is no known treatment, it is important to minimise the risk of its development by using the lowest effective dose of antipsychotic. With the advent of the atypical antipsychotics, which appear to have a lower propensity to cause these adverse effects, it is essential to carefully monitor for the development of tardive dyskinesia and tardive dystonia. I recommend that screening should be performed and documented at least once a year for people on long-term treatment (see Abnormal Involuntary Movements Scale (AIMS), Appendix 10).
Use the AIMS instrument to screen for the presence of tardive dyskinesia at least once a year.
2. Anticholinergic effects These include dry mouth, constipation, blurred vision and urinary retention. In the elderly, antipsychotics can cause delirium, especially when used together with other drugs with anticholinergic effects (for example, antiparkinsonians or tricyclics). They may precipitate narrow angle glaucoma. Low potency agents such as chlorpromazine have the most pronounced anticholinergic effects, risperidone the least. 3. Sedation is thought to be due to histamine receptor blockade. Always advise patients of possible effects on driving, and the interaction with alcohol. 4. Postural hypotension Adrenoceptor blockade leads to a failure of the reflex constriction of veins in the lower limbs that normally occurs on standing. Patients should be advised to take care when rising, to sit on the edge of the bed before getting up, and to sit down if they feel faint or dizzy. This side effect is most pronounced with low potency antipsychotics such as chlorpromazine. 5. Sexual dysfunction Antipsychotics can cause erectile dysfunction and ejaculatory dysfunction. These effects are most pronounced with thioridazine and least with olanzapine and quetiapine. 6. Neuroleptic malignant syndrome This is a rare syndrome, but has a mortality rate of between five and 10 per cent. It presents with fever, muscular rigidity, autonomic instability (fluctuating pulse rate, blood pressure and respiratory rate) and delirium. Electrolytes, liver function and creatinine phosphokinase are elevated. It is a medical emergency, often requiring admission to an intensive care unit for supportive measures to lower temperature and to maintain blood pressure and hydration. Dantrolene is sometimes used to lessen muscle rigidity.
Neuroleptic malignant syndrome is a medical emergency that presents with fever, muscular rigidity, autonomic instability and delirium.
7. Retinal pigmentation, caused by the deposition of pigmented granules, can lead to decreased acuity, poor night vision and browning of vision.Those on thioridazine are most at risk. Any person on long-term thioridazine should have an annual ophthalmological examination.
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8. Photosensitivity People prescribed chlorpromazine are most at risk.They should be advised to wear a hat when out of doors and to use a blockout sunscreen.Yearly ophthalmological examinations for lens opacities are advisable for those on long-term treatment. 9. All of these drugs can cause ECG changes. Thioridazine can now only be prescribed to people with schizophrenia who have failed to respond to treatment with at least two other antipsychotic drugs. It is contraindicated in combination with other drugs that inhibit cytochrome P450 2D6 and drugs that prolong the QTc interval. It is also contraindicated in people with a history of cardiac arrhythmias or congenital long QT syndrome. Periodic monitoring of the QTc interval and serum potassium are required. People with a pretreatment QTc interval greater than 450 msecs should not receive the drug. It should be discontinued in patients with QTc greater than 500 msecs. Instances of sudden death have occurred with pimozide. 10. Hyperprolactinaemia is caused by dopamine receptor blockade in the tubuloinfundibular pathways. It may be manifest by galactorrhoea, amenorrhoea and reduced libido.
Atypical antipsychotics
These include risperidone, olanzapine, quetiapine, amisulpride and clozapine. They are thought to exert their action through the blockade of dopamine, and serotonin receptors. Clozapine is effective in 10 20 per cent of cases resistant to treatment with other antipsychotics. All have a lower propensity to cause extrapyramidal effects. They are effective in reducing both negative and positive symptoms. Risperidone, quetiapine, olanzapine and amisulpride are presently only available on authority prescription for people with schizophrenia. Clozapine can cause neutropaenia in 510 per cent of people and agranulocytosis in 0.51 per cent. It has also been associated with potentially fatal myocarditis and cardiomyopathy. Side effects include weight gain, sedation, postural hypertension, hypersalivation, constipation and a decrease in seizure threshold. Consequently, it can only be prescribed at sites registered with the Clozaril Patient Monitoring System.
The newer antipsychotics cause fewer extrapyramidal side effects and are associated with fewer negative symptoms. Clozapine is effective in some cases that are resistant to other antipsychotics.
The atypical antipsychotics are generally better tolerated than conventional antipsychotics, however, they are not free of adverse effects (see Table 13-1). Atypical antipsychotics, especially clozapine and olanzapine, have been linked to impaired glucose metabolism, weight gain, raised lipid levels and an increased risk of developing diabetes mellitus. Of particular concern are reports of patients treated with clozapine and olanzapine developing diabetic ketoacidosis shortly after initiation of the drug. Patients treated with these agents should be routinely screened for diabetes and other metabolic abnormalities, including raised lipid levels. Patients with other risk factors for diabetes should be monitored more closely.1
Antidepressants
The newer antidepressants are safer in overdose than tricyclics.
There are eight classes of antidepressants currently available in Australiatricyclics, tetracyclics, monoamine oxidase inhibitors (MAOIs), specific serotonin reuptake inhibitors (SSRIs), reversible
Henderson DC. Atypical antipsychotic-induced diabetes mellitus: how strong is the evidence? CNS Drugs 2002; 16:7789.
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inhibitors of monoamine oxidase (RIMAs), serotonin receptor antagonists, selective inhibitors of noradrenaline reuptake (SNRIs) and noradrenergic and specific serotonergic antidepressants (NaSSAs). For a list of the advantages and disadvantages of the different classes of antidepressants, see Table 13-3. Drug interactions with the newer antidepressants are shown in Table 13-2, and recommendations for changing antidepressants are given in Table 13-4. Antidepressants are used not only in the treatment of depression, but also in anxiety disorders such as panic disorder, and in chronic pain. Clomipramine and the SSRIs have been shown to be effective in the treatment of obsessions. All antidepressants can precipitate mania in people with bipolar mood disorder, but there is some evidence that this is less likely with SSRIs1. The concurrent administration of lithium or an anticonvulsant mood stabiliser lessens the likelihood of this occurring.
The concurrent administration of a mood stabilising drug together with an antidepressant can prevent the development of mania in people with bipolar disorder.
Patients need to be informed that these drugs take two to four weeks to begin to have their antidepressant effect. To prevent relapse after a first episode of major depression, they should be continued for at least six to 12 months.
There is a delay of between two and four weeks before antidepressants begin to have their antidepressant effect. Tricyclic antidepressants
These drugs have been available for some years and have proven efficacy, but they have a higher side effect burden than the newer antidepressants.They are thought to exert their antidepressant effect through inhibition of the reuptake of serotonin and noradrenaline into presynaptic neurones. Half-lives are between 15 and 30 hours, allowing a single dose, usually at night.The drugs should be started at a low dose, for example, 50mg at night, and then gradually increased over one to two weeks up to 150mg a day. Lower doses should be used in elderly people. Tricyclics are dangerous in overdose and can be fatal because of their effects on cardiac conduction and their propensity to lower seizure threshold. They may cause a variety of arrhythmias, including ventricular tachycardia, and complete heart block. Patients should be asked about any suicide plans. It is often advisable to prescribe only a weeks supply of the drug at a time.
Tricyclics can cause death in overdose through cardiac conduction abnormalities, seizures or respiratory arrest.
Adverse effects Tricyclics have a wide range of potential adverse effects. Patients should be informed of these before commencing treatment. 1. Anticholinergic effects include dry mouth, blurred vision, constipation, urinary retention and tachycardia. Tricyclics can cause an anticholinergic delirium, especially in the elderly. Amitriptyline and clomipramine are strong anticholinergics, whereas desipramine is relatively weak. 2. Sedation is thought to be due to histamine and alpha-adrenergic blockade. Amitriptyline and
Bazire S. Psychotropic Drug Directory 2001-2002: the Professionals Pocket Handbook and Aide Memoire. Bath, Bath Press, 2001.
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Medication
Dose
Pharmacological treatments Cochrane review2 14 studies based on 3401 participants. Risperidone (versus typical antipsychotics) greater clinical improvement little or no additional effect on positive or negative symptoms fewer drop outs Cochrane review3 5 studies based on 2911 participants Olanzapine (vs. typical antipsychotics) effective antipsychotic fewer drop-outs lower depression scores fewer extrapyramidal side effects
Clozapine
for those patients who have not responded to other antipsychotic medications (including risperidone and olanzapine)
Risperidone
1-6mg/day
first admission patients with schizophrenia patients with sub-optimal symptom management on traditional antipsychotics
risperidone lacks anticholinergic properties. patients switched from older antipsychotics (which often required the co-prescription of anticholinergics to reduce extrapyramidal side effects) to risperidone can suffer cholinergic rebound (flu-like symptoms)
Olanzapine
5-20mg/ day
first admission patients with schizophrenia patients with extrapyramidal side effects on traditional antipsychotics patients with sub-optimal symptom management on traditional antipsychotics
transient elevation of liver enzymes lower incidence of tardive dyskinesia compared to haloperidol
Medication somnolence fatigue postural hypotension dry mouth dyspepsia constipation dizziness rhinitis weight gain hyperglycaemia diabetes mellitus abnormal lipid levels
Dose
Quetiapine
150750 mg/day
first admission patients with schizophrenia patients with extrapyramidal side effects on traditional antipsychotics
Amisulpride
50800 mg/day
treatment of acute and chronic schizophrenic disorders in which positive and/or negative symptoms are prominent
Cochrane review5 19 studies based on 2443 participants Amisulpride (versus typical antipsychotics) more effective in improving global state, general mental state and negative symptoms as effective for positive symptoms fewer extrapyramidal side-effects
insomnia anxiety agitation tremor somnolence headache hypersalivation constipation nausea weight gain amenorrhoea galactorrhea hyperglycaemia diabetes mellitus abnormal lipid levels prolonged QT extrapyramidal side effects
dose for acute psychosis: 40800mg/day dose for predominantly negative sysmptoms: 50300mg/day contraindicated in combination with other drugs that cause QT prolongation, and care with drugs that can cause hypokalaemia
1, 2, 3, 4 & 5
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doxepin are quite sedating, desipramine less so. Patients should be advised not to drive until tolerance to this side effect has developed. They should also be advised of the potentiation of sedation by alcohol. 3. Postural hypotension, sexual dysfunction and weight gain are caused by alpha-adrenergic blockade. 4. Cardiac conduction abnormalities Tricyclics have a quinidine-like anti-arrhythmic action as well as antimuscarinic effects. They are contraindicated in people with severe conduction abnormalities (e.g. second or third degree atrioventricular block or right bundle branch block,) or within two months of a myocardial infarction. They should be used with caution in patients with ischaemic heart disease or ventricular arrhythmias.1 People over 40 years old or otherwise at risk should have a cardiovascular system examination and an ECG before commencing treatment with a tricyclic.These drugs can cause sudden death in children and young people. 5. Seizures Tricyclics lower the seizure threshold and should be used with care in people with a history of epilepsy. 6. Precipitation of mania.
SSRIs inhibit the breakdown of tricyclics and so should not be prescribed together with them.
Bazire S. Psychotropic Drug Directory 2001/02: the Professionals pocket handbook and aide memoire. Bath, Bath Press: 2000.
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Strength of interactions: +++potent, ++modest, +weak. Adapted from: Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T, Naismith S, Koschera A. Treating depression and anxiety in general practice: training manual. Kogarah, NSW: Educational Health Solutions, 1998.
The use of MAOIs is limited because of their propensity to cause serious adverse reactionsin particular, because of their dangerous interactions with other drugs and foods.
Hypertensive crisis This potentially fatal adverse reaction is caused by an interaction with foods that contain tyramine or other sympathomimetic amines, or with sympathomimetic drugs (e.g. cold remedies that contain phenylephrine and pseudoephedrine). A list of foods and drugs that must be avoided is shown in Table 13-5. Tyramine is usually metabolised by MAO-A present in the bowel wall and the liver. When the action of this enzyme is inhibited, tyramine enters the systemic circulation leading to the release of amines from peripheral nerve endings, which in turn may cause a hypertensive crisis. Symptoms include headache, flushing, photophobia, nausea and vomiting, and palpitations.
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Pethidine reaction The drug interaction with pethidine can cause fever, labile blood pressure, delirium and coma. MAOIs may need to be ceased before a general anaesthetic. Reaction with tricyclic antidepressants and SSRIs The interaction can cause a serotonergic syndrome with tremor, incoordination, diarrhoea, abdominal cramping, agitation, delirium, tachycardia, hypertension, coma and death. The common side effects of MAOIs include the following: postural hypotension dry mouth, blurred vision and constipation (anticholinergic) sexual dysfunction anorgasmia, impotence and ejaculatory failure arousal and insomnia for this reason, the drugs are usually prescribed in divided doses in the morning and at midday sedation some people are sedated rather than aroused.
Nefazodone
Nefazodone is a serotonin receptor antagonist. Adverse effects include dry mouth, nausea, sedation, dizziness, constipation, fatigue, light-headedness, blurred vision and tinnitus. The incidence of sexual dysfunction is said to be less than with SSRIs. The manufacturer recommends a gradual increase in dose from 50mg bd in the first week to 200mg bd in the third week. Recommended therapeutic doses are between 300mg and 600mg a day.
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sertraline: 50 200mg once daily fluoxetine: 10 40mg once daily paroxetine: 10 40mg once daily fluvoxamine: 50 200mg once daily citalopram 20 60mg once daily 200 600mg in divided doses with evening preference 75 375mg in divided doses with evening preference
relative safety in overdose non-sedating effective in the treatment of obsessive compulsive disorder
side effects may include sexual dysfunction, nausea, diarrhoea, agitation, anxiety, sleep disturbance, headache and fatigue, especially early in treatment drug interactions (see Table 13-2): including inhibition of breakdown of tricyclics
no sexual side effects useful in the treatment of anxiety effective in severe depression few drug interactions short half-life non-sedating no sexual side effects few drug interactions use in depression with fatigue low incidence of agitation, sexual dysfunction, nausea and vomiting useful in treatment of anxiety symptoms and insomnia little effect on cyt P450 few drug interactions relative safety in overdose relative safety in the elderly and medically ill non-sedating use in atypical depression
Serotonin and noradrenaline reuptake inhibitors (venlafaxine) Reversible inhibitors of monoamine oxidase A (RIMAs) (moclobemide) Noradrenergic and Specific Serotonergic Antidepressants (NaSSA) (mirtazapine)
sedation, dry mouth, constipation, blurred vision, nausea, fatigue and tinnitus drug interactions (P450 3A4) relatively high side effect burden: nausea, anxiety, fatigue, headaches, sexual dysfunction, elevated blood pressure withdrawal syndrome side effects: nausea, anxiety, insomnia, headache, agitation and dizziness interactions with pethidine and cimetidine sedation, weight gain, dry mouth and headache
30 90mg in divided doses with evening preference phenelzine: 45 90mg a day in divided doses with morning preference tranylcypromine: 20 60mg a day in divided doses with morning preference
sedation potential to cause neutropaenia and polyarthritis (rare) potentially fatal hypertensive crisis as result of tyramine reaction severe interactions with pethidine, tricyclics and SSRIs side effects: postural hypotension, insomnia and agitation
Adapted from: Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T, Naismith S, Koschera A. Treating depression and anxiety in general practice: training manual. Kogarah, NSW: Educational Health Solutions, 1998.
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Mianserin
No antidepressant-free interval required
Fluoxetine
1-week antidepressantfree interval (taper TCA dose in this period) if short-term TCA treatment
Other SSRIs
1-week antidepressantfree interval (taper TCA dose in this period) if short-term TCA treatment
Mianserin
Fluoxetine
Start TCA at low dose Start at low dose (TCA serum levels may be elevated for several weeks due to persisting SSRI-induced CYP 2D6 inhibition) Start TCA at low dose Start at low dose (TCA serum levels may be elevated for several weeks due to persisting SSRI-induced CYP 2D6 inhibition 1-day drug-free interval (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs No antidepressant-free interval required 1-day drug-free interval (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs No antidepressant-free interval required Start at low dose
Other SSRIs
Moclobemide
1-day drug-free interval (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs 1-week antidepressantfree interval (taper venlafaxine dose in this period) if short term venlafaxine treatment
1-day drug-free interval (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs 1-week antidepressantfree interval (taper venlafaxine dose in this period) if short term venlafaxine treatment
Nefazodone
Irreversible MAOIs
Mirtazapine
Adapted from Stuart Baker. Changing from one antidepressant to another. Drug Wise 1997; 21:46 Pharmacological treatments
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Venlafaxine
Nefazodone
Irreversible MAOI
Mirtazapine
Careful cross taper
No antidepressant-free Reduce gradually then interval required (i.e. wait for 4 days start day after stopping) if moderate doses of both drugs. 1-week antidepressantfree interval for clomipramine No antidepressant-free Reduce gradually then interval required if wait for 4 days moderate doses of both drugs Taper high dose fluoxetine, cease before starting moclobemide. From low-moderate fluoxetine doses, no antidepressant-free period needed*
Taper TCA gradually, 1-week antidepressantcease, then wait 3-4 days. free interval Start nefazodone at 50mg twice daily
Taper TCA gradually, 1-week antidepressantcease, then wait 34 days. free interval Start nefazodone at 50mg twice daily
2-week antidepressant- 12 week antidepressant- 5-week antidepressantfree interval. Start free interval. Start free interval venlafaxine at low dose nefazodone at 50mg twice daily
Taper high dose 3-day antidepressantSSRI gradually and free interval. Start cease before starting venlafaxine at low dose moclobemide. From low-moderate SSRI doses, no antidepressantfree period needed* 1-day drug-free interval (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs Taper high dose venlafaxine gradually and cease before starting moclobemide. From low-moderate venlafaxine doses, no anti-depressant-free period needed* Start at low dose until more information available, or if cautious a 1-week antidperessantfree interval Suggest a 3-day antidepressant-free interval and start at low dose until more information available
1-day drug-free interval Careful cross taper (from high dose of moclobemide). No drug-free interval (i.e. start day after stopping) if moderate doses of both drugs 1-week antidepressantfree interval Careful cross taper
No drug-free interval 2-week antidepressant- 2-week antidepressantif moderate doses of free interval free interval both drugs but continue dietary restrictions for 2 weeks Careful cross taper Careful cross taper
2-week antidepressant- 2-week antidepressantfree interval (rare reports free interval of sudden death with abrupt switch)
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Venlafaxine
Venlafaxine is an inhibitor of the reuptake of serotonin and noradrenaline (SNRI). It has proven efficacy in severe depression. However, its use is limited by a relatively high side effect burden and discontinuation symptoms. Adverse effects include nausea, decreased appetite, fatigue, anxiety, headache, dizziness, insomnia or somnolence, increased sweating, sexual dysfunction and increased blood pressure. Discontinuation symptoms include headache, nausea, fatigue, dizziness and dysphoria. Recommended doses are between 75 and 375mg a day in divided doses.
Venlafaxine is a potent antidepressant. Its use is sometimes limited by its side effects and withdrawal effects. Mirtazapine
Mirtazapine is a Noradrenergic and Specific Serotonergic Antidepressant (NaSSA). It enhances both noradrenergic and serotonergic transmission while at the same time blocking 5HT2 and 5HT3 receptors. The blocking action permits selective 5H1 stimulation and, as a consequence, limits the occurrence of troublesome serotonergic side effects such as insomnia, sexual dysfunction, anxiety, agitation and headache, nausea and vomiting.The principal side effects are sedation (due to its antihistaminic action), weight gain, dry mouth (an adrenergic effect) and headache. It has a low propensity for drug interactions and generally, no withdrawal symptoms. Recommended doses are between 15 and 45 mg/day, given as a once daily dose at night. Paradoxically, sedation may be more pronounced at low compared to high doses.
Antimanic drugs
Lithium
Lithium is the treatment of choice for mania, both in the acute phase and in its prevention. The half-life is between 10 and 40 hours.Therefore, it takes between 2 and 10 days to reach a steadystate concentration. It is eliminated through renal excretion and so must be prescribed with care in people who suffer renal impairment, including those with congestive cardiac failure. Its therapeutic range is between 0.5 and 1.2mmol/L, but higher levels (up to 1.4mmol/L) may be needed in the treatment of acute mania. Levels between 0.6 and 0.8mmol/L are usually adequate for prophylaxis. Lithium is usually started at a dose of around 250500mg bd with the serum level being checked after five days and necessary adjustments then being made to the dose. Before commencing lithium, tests of renal function and thyroid function should be performed. We recommend the following monitoring regime for those on long-term lithium: serum lithium every 3/12, renal function (electrolytes, creatinine and urea) every 6/12, and thyroid function annually.
Serum lithium should be checked every 3/12, renal function every 6/12 and thyroid function every 12/12.
At therapeutic levels, lithium can cause a fine tremor, muscle weakness, problems with memory and concentration, weight gain, polydipsia and polyuria (in 1530 per cent of people), and rarely, extrapyramidal effects. Long-term adverse effects include hypothyroidism and euthyroid goitre. These can be treated with thyroxine replacement.
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Products home-made from unpasteurised milk e.g. yoghurt from unpasteurised milk
Aged meat or liver products (e.g. pate), dry sausage (e.g. salami); smoked or pickled fish (e.g. rollmops); soy products like miso and fermented soybean, curd or paste. Expired (out of date) cream Banana chips and banana flavoured dessert (banana peel is used in flavouring)
Desserts
Soups
Commercial soup bases, packet soups, tinned soups (use before expiry date) Coffee substitutes (e.g. Ecco) and up to a total of two standard glasses of red wines, white wines, port or manufactured beer Raspberry jam, chocolate Bonox, Bovril, aged non-alcoholic beer (check expiry date) home-brewed beer, protein drink Vegemite, Marmite, Promite, brewers yeast
Drinks
All permitted except some alcoholic beverages, beef and yeast extracts
Miscellaneous
Sugar, jam, honey, marmalade, salt, pepper, herbs, spices, vinegar, essences, flavouring syrups, sauces, confectionery (lollies)
Reproduced from:Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd edition, North Melbourne,Victoria,Victorian Medical Postgraduate Foundation Therapeutics Committee, 1995.
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Toxic effects occur typically at levels above 2 mmol/L, but can occur at around 1.2 mmol/L. They include course tremor, nausea and vomiting, polydipsia and polyuria, dysarthria and ataxia, confusion, disorientation and delirium. Patients must be informed about these effects and the possible causes, including: dehydration secondary to diarrhoea, vomiting and excessive sweating (in fever or hot weather); interaction with thiazide and loop-acting diuretics, nonsteroidal antiinflammatory drugs, and ACE inhibitors; and overdose.
Patients must be informed about the signs of lithium toxicity: tremor, nausea and vomiting, polyuria, polydipsia, slurred speech, ataxia and delirium.
Treatment of toxicity involves cessation of lithium and the restoration of fluid balance. Toxicity can cause irreversible brain damage and impaired renal concentrating ability.
Treatment of lithium toxicity involves cessation of lithium and restoration of fluid balance.
Lithium can cause congenital malformations, in particular, the cardiac Ebstein anomaly.Therefore, it is usually contraindicated during pregnancy, especially in the first trimester. Young women of childbearing age must be informed of this risk and given contraceptive advice. Lithium is excreted in breast milk, attaining concentrations in the infant between 0.1 and 0.5 those in the mother.
Drug interactions limit the use of carbamazepine with many other medications. The following drugs inhibit the metabolism of carbamazepine: cimetidine, erythromycin, isoniazid, verapamil, dextro-propoxyphene and diltiazem. Since carbamazepine can enhance its own metabolism, levels should be checked periodically to maintain a therapeutic dose. It also increases the metabolism and so lowers the plasma levels of oral contraceptives (leading to contraceptive failure), other steroids, phenytoin, theophylline, warfarin, tricyclic antidepressants and antipsychotics.
The large number of potential drug interactions limits the use of carbamazepine Sodium valproate
The mode of action of sodium valproate in the treatment of mania is not known. Valproate has a half-life of between 8 and 20 hours and so takes between two and five days to reach steady state. Doses usually begin at 200mg bd.The anticonvulsant levels are used as a guide to monitoring dose. There is some evidence that the use of a loading dose of valproate in the treatment of mania reduces the amount of antipsychotic required, and may shorten the length of the episode. Adverse effects include nausea and vomiting, weight gain, thinning of hair, ankle swelling and sedation.More serious adverse reactions include hepatotoxicity,pancreatitis and thrombocytopaenia. Periodic checks of liver function and blood count are therefore recommended. Sodium valproate should not be prescribed during pregnancy, especially in the first trimester, because of the risk of it causing spina bifida.
Sodium valproate should not be prescribed during pregnancy, especially during the first trimester.
Benzodiazepines are useful adjuncts to antipsychotics in the treatment of agitated psychotic patients.
They have their effect through increasing the inhibitory effect of gamma amino butyric acid (GABA) on receptors in the central nervous system. The fall in blood level and termination of action after a dose of diazepam is initially through redistribution to fat stores. However, if the drug is taken regularly over a few weeks, removal of the drug is by metabolism, a much slower process. Longer acting benzodiazepines include diazepam (half-life 20100 hours) and clonazepam. Shorter acting drugs include temazepam, alprazolam and oxazepam. The long half-life of diazepam is due to its active metabolites. Pharmacodynamic tolerance to the sedative effects of the drug develops within weeks. However, tolerance to the anxiolytic effects does not seem to occur. Sudden withdrawal can lead to agitation, anxiety, insomnia, nausea, hallucinations, delirium and seizures. Interactions occur
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with other CNS depressants. Adverse effects include sedation, impaired fine motor coordination, dysarthria, nystagmus, ataxia and memory problems. In the elderly, ataxia can lead to falls and serious injury. Cognitive impairment may also be more severe in this group.The benzodiazepines are much safer than the barbiturate hypno-sedatives that they replaced. However, in overdose, death can result from respiratory depression, asphyxiation or inhalational pneumonia. These drugs should not be prescribed to people with myasthenia gravis or severe respiratory depression. Indications for the use of benzodiazepines include: the short-term treatment of insomnia the treatment of insomnia over the first two weeks of treatment with an SSRI as an adjunct to antipsychotics in the treatment of an agitated psychotic patient the treatment of akathisia the treatment of alcohol withdrawal as a preanaesthetic. Although antidepressants and benzodiazepines are effective anxiolytics, I recommend cognitive behavioural therapy as the first line treatment of anxiety disorders (see Chapter 15). Cognitive behavioural therapy is at least as effective as pharmacotherapy; it is non-toxic, non-addictive and is associated with lower relapse rates than pharmacotherapy. However, at times, a combination of both approaches is required.
Zolpidem
Zolpidem is an imidazopyridine that is used for the short-term treatment of insomnia in adults. It selectively binds to the omega-1 (benzodiazepine-1) receptor, part of the GABAA receptor complex, but is chemically unrelated to benzodiazepines. The usual dose is 10mg at night; 5 mg in elderly debilitated patients and those with hepatic impairment. The most common adverse effects are dizziness, nausea, drowsiness and diarrhoea. It has a short elimination half-life of around 2.4 hours with a duration of action up to six hours1.
Zopiclone
Zopiclone is a cyclopyrrolone agent that is an agonist at GABAA receptors. It is used for the short-term treatment of insomnia. Usual doses are between 7.5mg and 15mg at night; 3.75 mg in the elderly and those with hepatic impairment. Side effects include bitter aftertaste and, more rarely, dry mouth, daytime sleepiness and nightmares2.
Adis editors. Drug of the month Stilnox. Generic Name: Zolpidem Tartrate Current Therapeutics. 2001; 42:79-81. 2 Noble S, Langtry HD, Lamb HM. Zopiclone: an update of its pharmacology, clinical efficacy and tolerability in the treatment of insomnia. Drugs. 1998, 55: 277-302.
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Chapter 14
Depression
Around 10 per cent of people presenting to general practitioners suffer from depression. Making a diagnosis is often difficult because mixed depression and anxiety occurs more frequently than depression or anxiety alone, and people often present with somatic rather than psychological symptoms. General practitioners see people with disorders across the broad spectrum of depressive illness from the milder forms through to severe melancholia and psychotic depression. The high prevalence minor depressive syndromes, though not containing florid symptoms, are nevertheless associated with substantial disability and handicap, higher than that associated with most physical disorders1. Moreover, because of their high prevalence, the overall economic burden of these disorders on the community is substantial. This chapter covers the assessment and treatment of depression and post-partum disorders. Chapter 15 deals with the treatment of anxiety disorders. See Appendix 11 for a discussion of sleep disturbance, a common presentation in general practice.
Assessment
People use a variety of words to describe depressionfeeling down in the dumps, sad, despondent, gloomy, bored or out of sorts. In some, especially adolescents and children, the predominant mood is irritability. An essential feature of the more serious depressive syndromes is anhedonia, the loss of pleasure or interest in almost all activities. Assess anhedonia by first asking a (man) about his usual interests and activities. Then ask if he is getting as much pleasure as usual from them. Ask him when he last did something he really enjoyed.
An essential feature of serious depression is anhedonia, the loss of pleasure or interest in almost all activities.
Neurovegetative symptoms of depression include loss of appetite, insomnia (especially early morning wakening), diurnal mood variation (in which the person feels most depressed in the morning with improvement in mood as the day progresses), loss of energy and motivation, reduced libido, difficulties with concentration and memory, and psychomotor retardation or agitation. Older sufferers may present with depressive pseudodementia. Depressed people often experience feelings of hopelessness, i.e. that they have no future. Ask about future plans and goals. This symptom is a stronger predictor of suicide than depressed mood. Helplessness, the feeling that nothing and nobody can alleviate a persons suffering, may also be present. A persons self esteem is lowered in depression. Depressed people are often plagued by feelings of worthlessness and guilt.They may be preoccupied with thoughts of death and dying. Always ask direct questions about any suicidal thoughts, intentions and plans (see Chapter 3 for a discussion of the assessment of suicidality). In view of the frequent co-morbidity with anxiety disorders, it is important to note the presence of panic attacks, obsessive-compulsive symptoms and phobias.
Wells KB, Stewart A, Hays RD et al. The functioning and well-being of depressed patients: results from the medical outcomes study. Journal of the American Medical Association 1989; 262: 914-919.
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The commonest conditions seen in general practice are mixed anxiety/ depressive disorders, often presenting with physical symptoms.
There are several possible reasons why people present in this way. Physical symptoms are features of both depression and anxiety. People may be better able to recognise and articulate their physical symptoms than their mental symptoms. They may believe that doctors are primarily skilled in the treatment of physical disorders. Doctors who are uncomfortable dealing with emotional issues, or who are pressed for time, may reinforce these attitudes. People may be reluctant to acknowledge mental symptoms because of the stigma of mental illness. They may be unaware that effective treatments exist for these conditions. The SPHERE-GP is a self-report questionnaire that is useful in the assessment of people presenting with a combination of somatic and psychological symptoms (see example in Appendix 1). The CES-D scale is a self-report depression scale for use in the general population1.
When depression and physical illness occur together, the prognosis for both conditions is worse.
Lists of physical disorders and drugs that can cause depression can be found in Tables 17-5 and 17-7.
Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Applied Psychological Measurement. 1977; 1:385-401.
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Depression
Diagnosis
The main depressive syndromes seen in general practice are adjustment disorders, dysthymia and major depression.The prototype for these disorders, major depression, will be discussed first. However, this is not the most prevalent condition in general practice settings. Disorders with milder symptoms are more common. Moreover, as many as 50 per cent of people who present to general practitioners feeling depressed have symptoms that do not meet the criteria for any of these disorders.
As many as 50 per cent of people who present to general practitioners with depression have symptoms that do not meet the criteria for a specific disorder.
Major depression The essential features are persistent symptoms over at least two weeks of depressed mood or loss of pleasure or interest (anhedonia) together with at least four of the following: change in appetite, weight loss or weight gain, insomnia or hypersomnia, psychomotor retardation or agitation, fatigue or loss of energy, feelings of worthlessness or guilt, poor concentration or indecisiveness, recurrent thoughts of death or suicidal thoughts, plans or acts1. In adolescents and children the mood may be predominantly irritable. Dysthymic disorder This refers to a chronic low-grade depressive syndrome. The DSM-IV requires a duration of at least two years in adults, and at least one year in children and adolescents. The symptoms are not as severe as in major depression and, although persisting for years, may not be present every day over that period. In particular, persistent anhedonia is not a feature. However, because of its chronicity, high levels of disability and handicap may accompany the symptoms. It is the commonest depressive diagnosis in children who present with chronically depressed or irritable mood, low self-esteem and a perception of being unloved.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Association, 1994.
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Adjustment disorder Adjustment disorders are reactions that occur within three months of the onset of a stressor, involving symptoms and levels of disability and handicap that are more than would normally be expected. Symptoms may include marked distress, depressed mood, tearfulness, anxiety, irritability or multiple physical complaints. Disabilities and handicaps include interpersonal withdrawal, conduct disturbance (for example, reckless driving, fighting or truancy) and poor work or academic performance. Psychotic depression Depressed people often become preoccupied with concerns about their physical health, their finances and feelings of worthlessness and guilt. In some cases, these beliefs are delusional. There may be nihilistic delusions (e.g. the belief that ones internal organs are rotting or no longer exist, or that the world is going to end), delusions of poverty, hypochondriacal delusions (e.g. that one has cancer) or delusions of guilt. The depressed person may suffer hallucinations (e.g. voices saying that he or she is worthless and evil). The diagnosis of psychotic depression indicates the need for specialist referral, hospitalisation, drug treatment and often, ECT. Bipolar disorder (manic depression) Episodes of depression may alternate with episodes of mania. The symptoms and signs of mania include elevated mood, grandiosity, a decreased need for sleep, pressure of speech, flight of ideas, increased energy and activity levels, and impaired judgement. Lithium is the mainstay of treatment. Inpatient care is usually required for the treatment of manic episodes. Psychiatric referral is recommended. Please refer to Chapter 22 for a more detailed discussion of treatment of psychotic illnesses.
Differential diagnosis
See Tables 17-5 and 17-7 for lists of physical disorders and substances that can cause depression. While the apathy and poor concentration of the person with dementia may be mistaken for depression, the two syndromes frequently co-exist, especially early in the course of dementia. As mentioned above, depression is often co-morbid with anxiety disorders.The negative symptoms of people with schizophrenia may be mistaken for depression. However, these people are also prone to developing depression (see Chapter 22).
Formulation
The formulation of depression always involves contributions of biological and psychosocial factors. While the diagnosis is an essential guide to treatment, a formulation is required for the development of a comprehensive treatment plan. In particular, for the 50 per cent of people whose symptoms fail to fit any of the recognised syndromes, the formulation is the principal guide to treatment. Biological factors As discussed above, depression often arises in response to the stress of having a physical illness, especially life threatening and chronic disorders, illnesses with distressing symptoms, and conditions associated with high levels of disability and handicap. Alternatively, physical disorders and drugs can cause depression (see Table 17-5 and Table 17-7). Have a high index of suspicion about an organic cause of depression in an elderly person presenting for the first time with depression. A family history of depression may suggest that genetic factors are playing a part in the inheritance of a primary depressive disorder, especially bipolar disorder.
Life threatening and chronic disorders, illnesses with distressing symptoms, and conditions associated with high levels of disability and handicap are often complicated by the development of depression.
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Depression
Psychosocial factors Depression may complicate other mental disorders. The frequent co-morbidity with anxiety disorders has already been mentioned. Between 30 and 40 per cent of people with panic disorder or obsessivecompulsive disorder also suffer from depression. Depression may also complicate schizophrenia, alcohol and substance abuse, dementia, somatisation disorder, chronic pain, anorexia nervosa and bulimia. People with personality disorders are vulnerable to depression, especially those with dependent, obsessional and narcissistic traits (see Chapter 23).
Between 30 and 40 per cent of people with panic disorder also suffer from depression.
Psychodynamic theories may offer insight into the meaning of an individuals response to loss. In Mourning and Melancholia, Freud1 observed that, unlike the person going through a normal mourning process, the person who becomes depressed following a loss suffers a critical fall in self-esteem. The depressed person is excessively self-critical and suffers feelings of worthlessness and guilt. In the same essay, Freud concluded that the depressed persons anger towards a lost person is often directed against the self. Other psychodynamic theorists view depression as being caused by a narcissistic injury. That is, depression occurs as a result of people not living up to the high expectations they have of themselves. It is the difference between ideals and reality that leads to depression and the attendant low self-esteem and feelings of worthlessness (see example in Box 14-1).
Arieti2 postulated that people prone to depression tend to subjugate their own needs and wishes to those of another person (the dominant other) in order to gain his or her affection, attention or approval. In other cases, a man may invest all his energies in the goals of some ideology or organisation.
Freud S. Mourning and Melancholia. In On Metapsychology:The theory of psychoanalysis. Pelican Freud Library. 1917 11:245-268. 2 Arieti SS. Suicide and the hidden executioner. International Review of Psychoanalysis. 1980 7: 57-60.
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Social factors Around 40 per cent of acute episodes of mood disorder are precipitated by stressful events. Stress is a commoner precipitant of depression than non-adherence to medication. Perceived criticism from a spouse is a high predictor of relapse in depression. Similarly, a high expressed emotion (EE) at home (hostility, critical comments and enmeshment) increases the risk of relapse. A common precipitant is loss, especially of a close relationship. A recent loss may reawaken unresolved losses from a persons past. The anniversary of the loss of a close relationship may precipitate depression.
Treatment
General principles
As a rule, the most effective treatments of depression involve a combination of pharmacological and non-pharmacological interventions. An exception is the treatment of people with psychotic depression or catatonia who will require drugs and possibly ECT before being accessible to psychotherapy. At the other extreme are people with minor depression or an adjustment disorder in whom the efficacy of drug treatments is uncertain.
The most effective treatment of depression usually involves both pharmacological and non-pharmacological interventions.
The two forms of treatment work together synergistically. For example, psychotherapy may enhance the efficacy of drug treatments by addressing the meaning of a persons non-adherence. A depressed man may refuse to take his medication, because he believes that nothing can help him. Another may believe that he does not deserve to get better. A third may feel too ashamed to take medication because of the stigma of mental illness. In the following discussion, three arms of treatment are discussednon-specific interventions, drugs and psychotherapy.
Treatment setting
Most people suffering depression prefer to be treated at home rather than in hospital. Indications for hospitalisation include danger to self or others, social isolation, limited social supports, poor self-care, severe co-morbid substance abuse, psychotic symptoms and the requirement for ECT.
Non-specific interventions
The following non-specific interventions are applicable to the treatment of depression as well as anxiety and somatoform disorders with which it is commonly associated.
Non-specific treatments of depression are also applicable to the treatment of anxiety disorders and somatoform disorders. They include engagement in treatment, illness education, increasing daily activities, exercise programs, limiting excessive substance use and improving sleep habit.
Engagement in treatment It is essential to engage the patient in the treatment plan. Summarise the persons problems and note that they are characteristic of the syndrome of depression. Discuss the formulation and explain how this will guide treatment for that individual. Link the different treatment approaches to specific aspects of the problemthe efficacy of medication in relieving some of the symptoms; counselling and structured problem solving to address specific stressors; cognitivebehavioural approaches to change habitual negative ways of thinking about oneself, the future and the world;
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interpersonal therapy to improve social functioning; grief work to deal with losses; and marital or family therapy to deal with relationship problems. Illness education Educating people about depression promotes their active involvement in treatment and addresses any misconceptions they have about the illness. Because of the stigma attached to mental illness, patients knowledge of depression is often limited and they are often reluctant to accept the diagnosis or adhere to treatment. Some guidelines for educating the depressed patient about depression are shown in Table 14-2. The beyondblue website, www.beyondblue.org.au, contains useful resources, including accounts of personal experiences of depression, patient information leaflets, a multimedia library with video clips, research reports and discussion-room transcripts.
Increasing daily activities As a consequence of their loss of interest and pleasure, depressed people often withdraw from their usual work, leisure and social activities. They often lose confidence and feel that they can no longer do the things they used to do, or that others will not want to see them. They become avoidant because of co-morbid anxiety symptoms.Through inactivity, they lose access to sources of pleasure and self-esteem. A vicious cycle is created in which depression leads to avoidance, which in turn reinforces depression. Conversely, having a wide range of interests and social contacts helps prevent relapse. Explain this to the patient. Ask him or her to make out a daily activity schedule for the week that includes some pleasant activities, some duties and some social activities (see Appendix 7). Involve the family in widening the persons range of activities.
Tanner S, Ball J. Beating the Blues: a Self-help Approach to Overcoming Depression. Moorebank:Doubleday, 1989. 2 Burns DD. Feeling Good:The New Mood Therapy. Melbourne: Information Australia Group, 1980.
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Exercise A daily exercise program will reduce anxiety and improve physical health and the sleep/wake cycle. A regular hour a day of gentle exercise, such as walking, is preferable to brief irregular bursts of strenuous exercise. Alcohol and drugs Depressed and anxious people often turn to recreational drugs to alleviate their symptoms. Explain that while rising alcohol levels may briefly improve mood, falling levels cause depression and anxiety. Remind patients of the physical consequences of cigarette consumption and alcohol abuse. Sleep/wake cycle The sleep/wake cycle is frequently disrupted in depression with initial insomnia, early morning wakening, poor quality of sleep, and daytime fatigue and irritability.Table 14-3 contains guidelines for improving the sleep habit.
Pharmacological treatment
Drugs are particularly effective in the treatment of neurovegetative symptoms, anhedonia, psychomotor retardation, and psychotic phenomena such as delusions and hallucinations. They are less effective than psychotherapy in dealing with low self-esteem, guilt, hopelessness, social withdrawal and loss of motivation.
Drug treatments are most effective for the treatment of neurovegetative disturbance, anhedonia, psychomotor retardation and psychotic symptoms.
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Depression
There are presently seven classes of antidepressants available. All share similar efficacy, but have different side effect profiles. See Table 13-3 for a summary of their relative advantages and disadvantages. As a first line of treatment, I recommend one of the following classes of drugs: selective serotonin reuptake inhibitors (SSRIs), i.e. fluoxetine, paroxetine, sertraline, citalopram or fluvoxamine serotonin receptor antagonists, i.e. nefazodone selective noradrenaline reuptake inhibitors (SNRIs), i.e. venlafaxine reversible inhibitors of monoamine oxidase A (RIMAs), i.e. moclobemide tetracyclic antidepressants, e.g. mianserin As a second line: tricyclic antidepressants, i.e. desipramine, nortriptyline, imipramine, dothiepin, amitryptiline, doxepin I would only recommend the use of irreversible inhibitors of a monoamine oxidase (i.e. phenelzine or tranylcypromine) as a third line. It is probably best only to prescribe these drugs on the advice of a psychiatrist. It usually takes around two weeks before a therapeutic effect is evident. If there has been no effect after six weeks, consider the possible reasons listed in Table 14-4. If a change of drug is indicated, it is best to change to a member of a different class of antidepressant. Guidelines for changing antidepressants are shown in Table 13-4. Augmentation with lithium or thyroxine may be of benefit in treatment resistant cases. This is probably best done after consultation with a psychiatrist.
Explain to patients that their mood symptoms will only begin to improve after about two weeks, and that the antidepressant will need to be taken for six to twelve months in order to prevent relapse.
Antidepressant therapy should be continued for at least 6 months, and usually 12 months, in order to prevent relapse. Maintenance therapy may be indicated for people who have suffered three or more episodes of depression, two episodes within five years, or severe illness. Lithium carbonate is the drug of choice for bipolar depression and may be a useful adjuvant in treatment-resistant unipolar depression. Electroconvulsive therapy remains the most effective treatment for severe depressive illness and is especially effective in psychotic depression. It is essential to educate the patient about the use of these drugs (see Table 14-2).
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Use counselling and structured problem solving to help people deal with stressors associated with the onset of depression.
2. Cognitive Behavioural Therapy (CBT) This form of psychotherapy has proven efficacy in the treatment of mild and moderate depression. See Chapter 10 for a more detailed description of CBT. Prefer CBT over IPT in the treatment of people with few affectively charged events associated with the onset of their depression. CBT is less effective in people with significant cognitive dysfunction.
5. Marital/family therapy Perceived criticism by a spouse increases the risk of relapse in depression. A high level of expressed emotion (hostility, critical comments and enmeshment) is also a predictor of relapse. Marital conflict or the loss of a close relationship may be the precipitant of a persons depression. The pattern of a maladaptive relationship from the past may re-emerge in a persons current marital relationship. These issues can be dealt with in therapy.
Address family and marital problems in joint therapy with the persons spouse or other intimate.
However, you should be cautious when dealing with long standing patterns of interaction within families. In some cases, a persons symptoms and disabilities may come to play a part in maintaining equilibrium in the family system. A sudden change will have an impact on other members of the family and on the family system as a whole. An example of depression occurring in the context of marital problems is given in Box 14-2.
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6. Dynamically-informed treatment The success of any therapy will depend on the establishment of a therapeutic alliance. Listen to the person and empathise with how he or she feels. Acknowledge his or her suffering. Avoid bland reassurance, such as saying, But you have no reason to feel depressed.This may be perceived as unempathic and rejecting. Empathy will also help you to work with the person in formulating the reasons why he or she has developed depression and what steps need to be taken to overcome it. Having established a therapeutic alliance, the person will begin to transfer on to you feelings and attitudes held towards significant others in his or her life. For example, a dependent man may expect you to give him advice about how to solve his problems. Avoid repeating the patterns of his previous relationships. Instead, use the principles of counselling and structured problem solving to help him make decisions for himself. Other countertransference responses that are commonly experienced when treating people with depression include frustration and anger when a person fails to improve, boredom with a persons many complaints, guilt and helplessness that you cannot solve the problem, denial of the seriousness of suicidal behaviour, or an impulse to rescue them (see example in Box 14- 3). These reactions give you insight into how others in the persons life feel. In some cases, the responses of others may be exacerbating the depression. For example, some people who fail to improve seem to get a perverse pleasure out of your and their families inability to help. The sadistic wish to hurt others by making them feel anxious, guilty and de-skilled is sometimes the other side of masochistic self-denigration. In such a case, the limits of what you and the persons carers can do should also be acknowledged.
Countertransference reactions that can interfere with the treatment of depression include frustration, boredom, guilt, helplessness and impulses to rescue or to give inappropriate advice. Box 14-3: Transference and countertransference in depression
A 40-year-old man becomes depressed after his wife leaves him, taking their children with her. She has always been responsible for making the major family decisions. He would never state his views directly, even when he was against a particular decision. Despite several attempts, he has never managed to get his motor vehicle licence. His wife was scornful of his failure and eventually decided that they could not afford to pay for any more driving lessons or tests. In therapy, he expresses his helplessness and wish for you to tell him what to do. Comment: You resist the pressure to give him advice on what he should do. In doing so you avoid repeating the pattern of the relationship with his wife, the dominant other. Instead, you teach him structured problem solving strategies to help him find solutions to his problems himself
Monitoring progress
Ask the person to monitor changes in his or her symptoms and any side effects of medication over the course of treatment. The SPHERE Patient Treatment Pack1 contains forms for this purpose. The SPHERE-GP2 instrument can be used to monitor progress weekly over the first four weeks and then at 6, 12, 26 and 52 weeks (see Appendix 1).
Hickie I, Scott E, Ricci C, Hadzi-Pavolvic D, Davenport T, Naismith S, Koschera A. Treating Depression and Anxiety in General Practice:Training Manual. Kogarah: Educational Health Solutions, 1998. 2 Hadzi-Pavlovic D, Hickie I, Ricci, C. Somatic and Psychological Health Report: development and initial evaluation. Technical Report TR-97-002, School of Psychiatry, University of New South Wales, Academic Department of Psychiatry, The St George Hospital and Community Health Service, 1997.
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Post-partum disorders
The three main syndromes are post-partum blues, postnatal depression and puerperal psychosis. Post-partum blues is a transient, self-limiting condition lasting hours to days. It is a common problem with a prevalence estimated at between 50 per cent and 70 per cent. It will not be discussed further here. Postnatal depression is a depressive syndrome with an onset in the postnatal period, that is, up to six months following childbirth. A depressive illness with an onset later than six months is best described simply as major depression. Puerperal psychosis is a psychiatric emergency with an onset during the first month after childbirth. It is rare with a prevalence of around 0.1 per cent.
Postnatal depression
Diagnostic assessment Most general practitioners will routinely screen for depression in all new mothers. A useful instrument is the Edinburgh Postnatal Depression Scale (Appendix 11). In the clinical assessment, ask about the symptoms of depressiondepressed or irritable mood, anhedonia, vegetative function change, anxiety symptoms, suicidality, helplessness and hopelessness. Note any persistence of symptoms of the blues. Observe any problems the mother has dealing with the babyfor example, not wanting to hold the child, feeling detached from or irritable with the child, or having persistent difficulties feeding him or her. Frequent attendance at the practice may indicate that the mother is having difficulty coping. Consider maternal depression if the baby has a difficult temperament, or has bad colic or reflux. Having made a diagnosis, make a formulation.
Indicators of postnatal depression include depressed or irritable mood, neurovegetative function change, persistence of the blues, problems coping with the baby and frequent medical consultations.
Formulation Biological factors predisposing to postnatal depression include a family history of mood disorder, a past history of mood disorder, a history of pre-menstrual syndrome, previous birth related crises, and complications of the birth or of drug treatments. Psychological factors include a vulnerable personality, the presence of depression during pregnancy and a past history of postnatal depression or anxiety. Social factors include relationship problems with the husband or the mothers parents. Assess the level of social support. Note any associated stressful life events (e.g. the need to give up a job, moving house or illness in the family).
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Take note, also, of factors relating to the pregnancy itself.These include depression, unplanned or unwanted pregnancy, obstetric complications, birth of a handicapped child or the birth process not proceeding according to expectations. Treatment Education Education about post-partum disorders before childbirth is a useful preventive strategy. For the woman who is suffering from postnatal depression, explanation about the disorder will provide relief in itself. Cognitive distortions typical of depression should also be corrected. For example, the mother may feel that she is a bad mother, that she is a failure, or that she is going insane. It is important to inform women who are suffering postnatal depression that the condition is not uncommon, that they are not alone in feeling this way and that it is not due to a failure on their part. Making it clear that the condition is understood and that effective treatments are available will reduce anxiety and helplessness. Psychotherapeutic approaches General supportive measures should be used. Allow her to ventilate her feelings. In particular, help her to acknowledge negative feelings about the birth of the baby. Point out that these negative feelings are not uncommon. Be careful, however, not to underrate her suffering and assess any potential for abuse of the child. Also, allow her to discuss any problems in the marriage or in the relationship with her parents. The birth may have necessitated role changes or a loss of work. In helping her to deal with practical issues, use structured problem solving rather than giving her advice on what she should do. Consider the use of specific techniques, such as cognitive behavioural therapy (see Chapter 10). Medication Indications for the use of medication include severe depression, vegetative function disturbance, psychomotor agitation or retardation, and co-morbid panic disorder. In choosing an antidepressant drug remember that there is little information presently about the safety of the newer drugs (SSRIs and RIMAs) for mothers who are breast-feeding. However, at the time of writing, a number of specialists in the area are prescribing sertraline to breast-feeding mothers with postpartum depression. The amount of tricyclics that appear in breast milk is not harmful. Referral Consider referral to appropriate community agencies. These might include Relationships Australia, Family Day Care and Community Child Health Nurses. Indications for referral to a psychiatrist include persistent suicidal ideation, poor response to treatment and severe personality problems.
Puerperal psychosis
This is a psychiatric emergency and requires specialist inpatient psychiatric care, preferably in a unit that will house both mother and baby. The disorder may present with psychotic symptoms (auditory hallucinations and delusions), mood lability (between depression, elation and irritability) or features suggestive of an organic disorder (confusion, incoherence). Suicidal ideation and ideas of harming the baby are not uncommon. In one study, five per cent of patients ultimately committed suicide, and there was a probable infanticide rate of four per cent1. Women who suffer the disorder may go on to develop schizophrenia or bipolar mood disorder. Consider medical conditions in the differential diagnosis (e.g. septicaemia, toxaemia, hypothyroidism, Cushings Disease or neoplasm).
Kaplan HI, Sadock BJ eds. Comprehensive Textbook of Psychiatry, fifth edition. Baltimore: Williams and Wilkins, 1989: 856.
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Chapter 15
Anxiety disorders
In contrast to fear, which is the response to a realistic and immediate danger, anxiety is a fearful response occurring in the absence of a specific danger, or in anticipation of imminent problems or challenges. In the face of an imminent threat to life, fear is adaptive and prepares us for fight or flight. A degree of arousal and anxiety improves performance, but high levels of anxiety diminish performance and can lead to decompensation (see Figure 6-1). Anxiety is only pathological when it is excessive in relation to the threat, persistent, and causes significant disability and handicap. The National Survey of Mental Health and Wellbeing found that anxiety disorders were the most common form of mental disorder in the population with a one-year prevalence of 9.7 per cent1. Mixed anxiety and depression is more common than any specific disorder alone. Table 15-1 lists some of the symptoms of anxiety. Between 50 and 95 per cent of people with anxiety disorders present with physical symptoms.
Assessment
Many of the physical symptoms of anxiety are caused by hyperventilation. Over-breathing causes a lowering of pCO2, which in turn produces an increase in pH. The elevated pH causes vasoconstriction in cerebral arteries and increased binding of oxygen to haemoglobin, which in turn leads to cerebral hypoxia.
Cognitions
Behaviours
Physical symptoms
Andrews G, Hall W, Teeson M, Henderson S. The Mental Health of Australians, Mental Health Branch, Commonwealth Department of Health and Aged Care, 1999.
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The non-specific approaches used in the treatment of depression are also applicable to the treatment of anxiety disorders.They include education, the use of daily activity schedules, taking regular exercise, limiting the consumption of cigarettes and alcohol and improving the sleep/ wake cycle (see Chapter 14). Cognitive and behavioural therapies are the mainstays of treatment. Benzodiazepines are effective anxiolytics, but impair performance and can lead to dependence.
The non-specific approaches used in the treatment of depression are also important elements in the treatment of anxiety disorderspatient education, daily activity schedules, exercise programs, limiting cigarette and alcohol consumption and improving sleep habit.
An excellent reference for the treatment of anxiety disorders is Management of Mental Disorders, Volume 11. This volume contains detailed descriptions of treatments, as well as handouts for patients. See Appendix 11 for a discussion of the management of sleep disturbance, a common presentation in general practice.
Differential diagnosis
Some physical disorders and substances that can cause anxiety are listed in Tables 17-6 and 17-8.Anxiety symptoms, including panic attacks, phobias, obsessions and compulsions commonly occur in major depression. People with psychotic disorders may suffer anxiety symptoms as part of their disorder (e.g. obsessivecompulsive symptoms in a man with schizophrenia), in which case the diagnosis of psychosis subsumes the diagnosis of an anxiety disorder. However, people with psychosis may also develop anxiety symptoms secondary to their psychosis (e.g. the man who develops agoraphobia in response to his persecutory delusions).
Formulation
Biological factors There is an increased incidence of panic disorder and obsessivecompulsive disorder among first-degree relatives of sufferers, and concordance rates for monozygotic twins are higher than for dizygotic twins. Some physical disorders and drugs that can cause anxiety are listed in Tables 17-6 and 17-8. Behavioural theories Classical conditioning may explain the development of phobias and obsessions. Operant conditioning may account for phobic avoidance and compulsions (see Box 15-1). Children may learn anxiety by modelling their behaviour on that of a parent. Psychodynamic theories Psychodynamic theories are often useful in understanding the meaning of anxiety to an individual. In his later theories, Freud understood anxiety as a signal of danger when unconscious sexual and aggressive drives that are in conflict with the dictates of the superego threaten to overcome the repression imposed by the ego and enter consciousness. In some cases, secondary defences are then mobilised, which lead to the development of characteristic neurotic symptoms. Freud described four types of anxiety, classified according to their developmental origins. Superego anxiety is a fear of feeling guilty or ashamed. Castration anxiety, which is manifest by fears of retribution, is thought to arise from unresolved conflict during the Oedipal stage of development. Separation anxiety is the fear of losing the love and care of important other people. The most primitive form of anxiety is id anxiety, a fear of disintegration or persecution.
Treatment Protocol Project. Management of Mental Disorders, 2nd Ed. World Health Organisation Collaborating Centre for Mental Health and Substance Abuse, 1997.
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Anxiety disorders
Operant conditioning
Other psychosocial factors Anxiety is frequently co-morbid with other mental disorders. Anxiety symptoms commonly occur in combination with depression. For example, between 30 per cent and 40 per cent of people with panic disorder or obsessivecompulsive disorder also suffer depression. Anxiety symptoms may also complicate schizophrenia, somatoform disorders, dementia and delirium. Anxiety disorders are often complicated by self-medication with alcohol and other substances. Conversely, substance abuse may be complicated by the development of anxiety symptoms.
Anxiety disorders are often co-morbid with depression and substance abuse.
Dependent, avoidant and obsessivecompulsive personality traits predispose to the development of anxiety disorders. A history of school refusal may indicate a predisposition to anxiety. As with other mental disorders, the onset of an anxiety disorder is often precipitated by life events. The precipitant may have particular meaning for the person in terms of his of her history. A failure to formulate a case may lead to inadequate treatment (see Box 15-2).
Andrews G, Hall W, Teeson M, Henderson S. The Mental Health of Australians Canberra: Mental Health Branch, Commonwealth Department of Health and Aged Care, 1999.
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The main feature is excessive anxiety and worry for most days over a period of at least six months. Associated symptoms include restlessness, being easily fatigued, difficulty concentrating or mind going blank, irritability, muscle tension and sleep disturbance.
Differential diagnosis
Generalised anxiety disorder is the closest disorder to normal anxiety, from which it is distinguished by the following: the worries in GAD are difficult to control and cause significant disability and handicap; they are more pervasive, severe and chronic, and may occur without any precipitant; and they are accompanied by a variety of physical symptoms (fatigue, irritability, restlessness and feeling on edge). Physical disorders and substances that can cause anxiety are listed in Tables 17-6 and 17-8. Especially common are caffeine intoxication, sedative and alcohol withdrawal, and stimulant abuse. Anxiety symptoms are common in depression, and may also arise in the context of psychotic disorders.
Treatment
1. Non-specific treatments as for depression daily activity schedules, exercise program and improving the sleep habit (see Chapter 14) 2. Educate the patient about the following: a) Normal anxiety, the fight or flight response, the physical symptoms of anxiety and their relationship to hyperventilation People with anxiety disorders are not always aware of some of their symptoms. For example, a man may present with fatigue, but only upon reflection and after self-monitoring, recognise his muscle tension. People will be relieved to understand the origins of their symptoms and feel more in control of them. Careful and thorough explanation alone will often lead to symptomatic improvement. b) The need to confront rather than avoid feared situations and so prevent the development of agoraphobia c) The dangers of becoming dependent on alcohol or benzodiazepines 3. Relaxation training: controlled breathing (see Appendix 4) progressive muscular relaxation (see Appendix 5) self-hypnosis (see Appendix 6) 4. Problem solving to deal with current stressors (see Appendix 3) 5. Cognitive-behavioural approaches to self-monitor for symptoms and to identify and challenge automatic thoughts (see Chapter 10) 6. Referral is indicated for people with severe and chronic symptoms that do not respond to the above psychological treatments. In some, medication may be indicated. Benzodiazepines may be used for the short-term treatment of symptoms, antidepressants (and occasionally benzodiazepines) for chronic symptoms. Patients prescribed benzodiazepines must be informed about side effects and the dangers of developing tolerance, dependence and withdrawal. 7. Evaluation of the outcome of treatment using the Hopkins Symptom Checklist1.
Derogatis LR, Lipman R, Rickels K, Uhlenroth EH, Covi L. The Hopkins Symptom Checklist (HSCL): a self-report symptom inventory. Behavioural Science, 1974; 19: 1-15
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Anxiety disorders
Panic disorder
The diagnosis of panic disorder is made when a person suffers recurrent panic attacks that cause significant distress or disability. In a panic attack, there is an abrupt onset of intense fear. The fear may be of losing control, of going mad or of dying. Associated symptoms include palpitations, sweating, shaking, chest discomfort, nausea, dizziness, light-headedness, derealisation, depersonalisation, paraesthesias and hot or cold flushes.
Differential diagnosis
In the differential diagnosis, it is important to assess whether the panic attacks are occurring in the context of a major depressive disorder. A variety of medical disorders may also cause panic attacks. These include hyperthyroidism, hyperparathyroidism and cardiac arrhythmias. Panic attacks can also be caused by intoxication with amphetamines, cocaine or caffeine. Lists of physical illnesses and drugs that can cause anxiety are provided in Tables 17-6 and 17-8. Other disorders in the differential diagnosis include hypochondriasis, psychotic disorders and other anxiety disorders.
Treatment
1. Non-specific treatments, as for depression (see Chapter 14) 2. Education about anxiety as above for generalised anxiety disorder 3. Controlled breathing techniques to abort panic attacks (see Appendix 4) 4. Relaxation techniques to prevent panic attacks Commonly used methods are progressive muscular relaxation (see Appendix 5) and self-hypnosis (see Appendix 6). 5. The use of tricyclic antidepressants or SSRIs when the above measures have not been effective on their own. 6. The avoidance of substance abuse to self-treat symptoms (especially alcohol and benzodiazepines). 7. Evaluation of the outcomes of treatment: a) Ask the person to record the frequency of panic attacks. b) Use the Hopkins Symptom Checklist (HSCL)1.
Agoraphobia
The essential feature of this disorder is a fear of being in places or situations from which escape is difficult. As a consequence, sufferers often avoid the feared situations. Typical agoraphobic fears include being away from home alone, being in a crowd, standing in line or travelling on public transport. Agoraphobia often complicates panic disorder. The avoidance behaviour may constitute a high level of disability.
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to understand how avoidance behaviours can be self-perpetuating. By lowering anxiety levels, avoidance behaviours are negatively reinforced. Avoidance of one situation can lead to avoidance of others with consequent higher levels of disability. A persons tolerance of anxiety will diminish as she or he avoids facing more and more feared situations. He or she should also be advised of the dangers of using alcohol or benzodiazepines to cope with anxiety. 3. Relaxation techniques controlled breathing, progressive muscular relaxation and selfhypnosis (see Appendices 4, 5 and 6) 4. Graded exposure This involves graded exposure to a hierarchy of feared situations (see Appendix 8). The two relaxation techniques discussed above should first be mastered. The person is then asked to make a list of feared situations and put them in order from least to most feared. He or she is then encouraged to work step-by-step through the list, confronting the situations using controlled breathing and muscular relaxation before each challenge, and using controlled breathing and selective muscle relaxation to manage anxiety during exposure. It is essential that the person stay in the situation until the anxiety has attenuated (habituation). Escape from the situation will only reinforce the avoidance behaviour. The treatment is time-consuming, often requiring around an hour a day over a month. The Subjective Units of Distress Scale (SUDS) can be used to document habituation of anxiety during exposure (see Figure 9-2) and desensitisation over repeated exposures (see Figure 9-3). 5. Evaluation of the outcome of treatment using the Fear Questionnaire1 or the Hopkins Symptom Checklist2 6. Referral to a psychiatrist, psychologist or specialist anxiety disorders unit if these measures fail.
Specific phobia
This involves marked and persistent fear when exposed to specific objects or situationsfor example, animals, flying, heights, receiving an injection or seeing blood. Avoidance behaviour can lead to significant disability.
Treatment
This is similar in principle to the treatment of agoraphobia. 1. Education about anxiety (as for panic disorder and agoraphobia, above) 2. Relaxation techniques:
controlled breathing (see Appendix 4) progressive muscular relaxation (see Appendix 5) self-hypnosis (see Appendix 6)
3. Graded exposure to the feared object or situation For example, a person suffering a bird phobia might progress from looking at a picture of a bird, to making a visit to the Currumbin Bird Sanctuary. 4. Avoidance of the use of benzodiazepines and alcohol to cope with feared situations
Marks IM and Mathews AM. Brief standard self-rating for phobic patients. Behavioural Research and Therapy. 1979,17: 263-267. 2 Derogatis LR, Lipman R, Rickels K, Uhlenhuth EH and Covil L. The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioural Science, 1974, 19:1-15.
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5. Evaluation of the outcome of treatment by asking the person to rate his or her level of anxiety when exposed to the feared situation using a SUDS score (see Figure 9-1). People with blood or injection phobias are at risk of fainting during medical procedures. An initial fight or flight response, mediated by the sympathetic nervous system, is followed by an intense parasympathetic discharge, resulting in lowered cerebral perfusion. Make sure the person is lying down before performing any procedures.
Social phobia
This disorder is characterised by marked and persistent fear when in the presence of unfamiliar people or when under the scrutiny of others. Specifically, the person fears shame or humiliation. Typical feared situations include eating, writing or having to speak in public, or being in a social situation where she or he may do or say something embarrassing. Panic attacks may occur during exposure. Avoidance behaviours can lead to significant disability.
Treatment
This is similar to the treatment of specific phobia. There is some evidence that antidepressant medication may also helpmoclobemide, fluoxetine or phenelzine. Propanolol may be used for symptoms of performance anxiety that suggest sympathetic overactivity (1040mg taken 30 to 60 minutes prior to the performance). It should not be used in those with asthma1.
People with social phobia are anxious in the presence of unfamiliar people or when they are under the scrutiny of others.
Obsessivecompulsive disorder
Symptoms include obsessions, that is, persistent and intrusive thoughts, impulses or images that the person attempts to ignore or suppress; and/or compulsions, that is, repetitive behaviours (e.g. hand washing, counting and checking) that are performed either in response to an obsession or according to rigid rules, in order to prevent some dreaded event.Typical obsessions include fears of contamination, doubting (e.g. a fear of having harmed others or of having left an electrical appliance switched on), a need to have things in a particular order (e.g. when hanging out clothes on the washing line) or fears of doing something terrible (e.g. assaulting someone). Compulsive behaviours are recognised, at least initially, to be excessive and not realistically connected with the situation that they are supposed to prevent. Disability results from the time spent on the compulsions, and through their interference with other activities.
Differential diagnosis
Tourettes disorder and temporal lobe disorders may be complicated by obsessivecompulsive disorder. Obsessivecompulsive symptoms may be the presenting complaint in people with depression. People with schizophrenia may suffer obsessions and compulsions in addition to their psychotic symptoms, or when their psychotic symptoms are in remission.
Treatment
1. Education a) about the disorder and its symptoms b) about how compulsive rituals are reinforced by causing a reduction in anxiety For example, a woman who has obsessional fears of contamination experiences mounting
Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd edition, North Melbourne, Victoria,Victorian Medical Postgraduate Foundation Therapeutics Committee. 1995.
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anxiety until she washes her hands 10 times according to her ritual. Performance of the ritual reduces her anxiety and so is negatively reinforced and begins to occur more frequently. Left untreated, the rituals begin to be used to neutralise anxiety in situations in which the possibility of contamination is more and more remote. The rituals become progressively more elaborate, time-consuming and rigid in their application. The increasing demands of performing the rituals lead to considerable disability. Treatment seeks to reverse this process by graded exposure to feared situations as described below. 2. Exposure with response prevention The person is asked to list situations that trigger the rituals. These situations are then rated according to how much anxiety each produces. The person is then asked to confront each situation in order from least feared to most feared, without performing the ritual. The person is instructed to stay in the situation until the anxiety attenuates (habituation). He or she documents desensitisation by recording levels of anxiety using a SUDS score (see Figure 9-1).
A core component of the treatment of obsessivecompulsive disorder is exposure of the person to the feared situation, while preventing the performance of the associated ritual.
3. The use of drugs that inhibit the re-uptake of serotonin, i.e. SSRIs or clomipramine.
Drugs that inhibit the re-uptake of serotonin are effective in the treatment of obsessivecompulsive disorder.
4. Evaluate the outcome of treatment using the Hopkins Symptom Checklist1 or the Padua Inventory2. Some people will respond well to a detailed explanation of their symptoms alone. It is generally not useful to repeatedly reassure sufferers that their obsessional fears are unrealistic. It is more effective for them to prove this for themselves. Exposure and response prevention is often very time-consuming and may be quite ineffective if performed in a haphazard manner. For example, it may take two hours for the anxiety to attenuate in the first session of exposure. General practitioners are advised to refer people who require complex treatment to a psychiatrist, psychologist or a specialist Anxiety Disorders Unit.
Derogatis LR, Lipman R, Rickels K, Uhlenhuth EH and Covil L. The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory. Behavioural Science, 1974, 19:1-15. 2 Sanavio E. Obsessions and compulsions: the Padua Inventory. Behaviour Research and Therapy. 1988, 26: 169-177. *Available from: Educational Health Solutions, Suite 13, 3rd Floor, St George Private Hospital and Medical Complex, 1 South Street, Kogarah, NSW 2217. 3 Andrews G, Hall W, Teesson M, Henderson S. The Mental Health of Australians. Mental Health Branch, Commonwealth Department of Health and Aged Care 1999.
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Anxiety disorders
Severe trauma can produce symptoms in the strongest of personalities. Traumatic events can endure and change personality. For instance, abuse suffered as a child may be an important factor in the origin of borderline personality disorder. Even adults who suffer severe trauma can undergo personality change as a result of their chronic post-traumatic symptoms.Treatment involves both drugs (imipramine or SSRIs) and psychotherapy. Specialist referral is indicated for severe or long-standing cases. The essential role of the general practitioner is to be aware of the risk of developing a psychiatric disorder in those who have suffered trauma, to observe them over the long term and to provide early intervention if necessary. (See also Chapter 21 for a more detailed discussion of dissociative disorders and other post-traumatic syndromes, including post-traumatic stress disorder).
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Chapter 16
The relationship between physical and mental illness
Unravelling the extent to which physical and mental disorders are contributing to a persons presenting problems is a common challenge facing a general practitioner. The SPHERE GP1 instrument can be of assistance (see Appendix 1). This chapter contains an overview of the relationships that can exist between physical and mental disorders. It concludes with a discussion of the importance of monitoring transference and countertransference responses when treating patients in general medical settings. It serves as an introduction to the following three chapters in which I discuss the assessment and treatment of organic mental disorders, substance abuse and somatoform disorders.
While the development of depression and anxiety disorders in response to suffering a physical illness may be understandable, these responses are not normal and they require treatment.
The assessment of depression in the context of a physical disorder is difficult because some of the symptoms could be caused by either condition (e.g. fatigue, loss of appetite, loss of weight and low energy levels).Take note of symptoms that cannot be accounted for by the physical disorder. Remember that people who are depressed may present with an exacerbation of their physical symptoms. Always consider a diagnosis of depression when any of the following symptoms are present: persistent feelings of worthlessness and guilt, anhedonia, hopelessness, suicidality, panic attacks, or psychomotor retardation or agitation.
Hadzi-Pavlovic D, Hickie I, Ricci C. Somatic and Psychological Health Report: development and initial evaluation. Technical Report TR-97-002, School of Psychiatry, University of New South Wales, Academic Department of Psychiatry, The St George Hospital and Community Health Service, 1997.
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a careful mental status examination with particular emphasis on the assessment of cognitive function. Note any physical symptoms, prescribed medications and recreational drug use. Follow up with relevant physical examination and investigations.
Have a high index of suspicion about an organic cause in the elderly person who presents for the first time with mental health problems.
In general practice populations, depression and anxiety disorders often present with physical symptoms.
People with chronic mental illnesses often suffer poor physical health.
Meier DE, Back AL, Morrison RS. The inner life of physicians and care of the seriously ill. JAMA December 19, 2001, 286: 3007-3014.
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transference responses. Chronic illnesses, which follow a progressive downhill course, may engender feelings of hopelessness, helplessness and frustration in patients and in those treating them (see also Chapter 7 for a discussion of bereavement and breaking bad news). Illnesses in which the prognosis and treatment options are unclear will test the doctors ability to tolerate uncertainty and ambiguity. It is difficult for doctors to maintain a professional distance and think clearly about clinical problems when treating certain individualspeople similar to themselves (especially other doctors), patients who remind them of others who are important in their lives (e.g. their children, spouse or parents), patients they have known for a long time, and people in the public eye. The powerful countertransference reactions engendered by patients with personality disorders may affect the doctors treatment behaviour (see Chapter 23). The judgement of doctors who are depressed, abusing substances, under stress or suffering burnout is impaired.Traits that are adaptive in some situations can lead to difficulties in othersa doctors perfectionist qualities may make it difficult for (him) to acknowledge the limitations of what can be done and lead him to undertake desperate measures in an attempt to rescue patients; he may have difficulty tolerating uncertainty in the prognosis and choice of treatment; he may isolate affect and fail to recognise his emotional reactions and how they are affecting his behaviour. Doctors may resent the demands placed on them by severely ill patients and their families, and have difficulty responding to criticism of their treatment.
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Chapter 17
Organic mental disorders
This chapter deals with the assessment and treatment of delirium, dementia and other mental disorders (anxiety, depression, personality change and psychosis) that are caused by physical illnesses or by drugs and other substances.
Delirium
Delirium is a syndrome caused by a reversible and global derangement of brain metabolism that includes behavioural, psychological and physical symptoms. Any medical condition or substance that directly or indirectly affects the central nervous system can cause delirium. Since delirium can present with any of the abnormalities seen on the mental state examination, it may be mistaken for a functional mental disorder, an error that can result in serious morbidity or even death. There is usually a relatively rapid onset of symptoms and signs in delirium. The critical clinical feature is an altered level of consciousness that can vary from mild inattention and clouding through to coma, and may fluctuate over time. Monitor your countertransference and be aware of feeling irritated if a person cannot give you a clear history or is otherwise uncooperative. This may be the clue to the diagnosis of delirium. Other signs include poor concentration and attention; disorientation in time, place and person; hallucinations, especially visual and tactile; reversal of the sleep-wake cycle; fleeting persecutory ideation; disorganisation of thinking and behaviour; and either psychomotor agitation or reduced activity and awareness.
The sudden onset of psychotic symptoms in a person over the age of 50 is likely to be a sign of delirium.
Important causes to keep in mind include alcohol and benzodiazepine withdrawal, infection (e.g. pneumonia, urinary tract infection and meningitis), drug toxicity (e.g. lithium, benztropine, carbamazepine, digoxin) subdural haematoma, subarachnoid haemorrhage, congestive cardiac failure and Wernickes encephalopathy. Drugs with anticholinergic side effects are particularly prone to cause delirium. These include tricyclic antidepressants, traditional antipsychotics (especially low potency agents such as chlorpromazine and thioridazine) and anti-Parkinsonian agents. The treatment of delirium involves placing the person in a safe physical environment (e.g. medical ward, nursing home or under close supervision at home); identifying and treating the underlying medical disorder; monitoring food and fluid intake; and providing symptomatic sedation. Suggested drug doses for use in the delirious patient are shown in Table 17-11. Many psychiatrists now prescribe risperidone in preference to haloperidol because of the absence of anticholinergic side effects. Use the least invasive route of administration that is practicaloral before intramuscular before intravenous. Monitor vital signs after administration of a sedative.
Victorian Medical Postgraduate Foundation Therapeutics Committee. Psychotropic Drug Guidelines. North Melbourne:Victorian Medical Postgraduate Foundation Therapeutics Committee, 1995.
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Avoid using benzodiazepines in people with respiratory depression. If the cause of the delirium is alcohol or benzodiazepine withdrawal, treatment will include administration of a cross-tolerant benzodiazepine such as diazepam.
Normal adult
Diazepam 510mg orally Midazolam 2.55mg intramuscularly Diazepam 510mg intravenously Haloperidol 1.510mg orally Risperidone 0.52mg orally Droperidol 510mg intramuscularly, or Haloperidol 510mg intramuscularly
Frail elderly
Diazepam 2mg orally Midazolam 1.25mg intramuscularly Diazepam 2mg intravenously Haloperidol 0.5mg orally Risperidone 0.51mg orally Droperidol 2mg intramuscularly Haloperidol 0.51.5mg intramuscularly
Dementia
Dementia is characterised by a decline in cognitive functioning that is severe enough to produce significant disability and handicap. In contrast to delirium, which involves an acute derangement of brain function, dementia is associated with progressive neuronal loss. Dementia always involves some loss of memory (learning new information and recalling previously learned information). Other cognitive disturbances include: a) aphasia b) apraxia c) agnosia d) executive function disturbance (planning, organisation, sequencing and abstraction).
Aetiology
The commonest cause is Alzheimers Disease (65 per cent of cases).Vascular dementia accounts for a further 10 per cent. Note, however, that at autopsy as many as 20 per cent have evidence of both Alzheimers Disease and vascular dementia. Around 15 per cent of dementias have some reversible component (see Table 17-2).
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Metabolic
hepatic encephalopathy uraemic encephalopathy cardiac arrhythmias cerebral hypoxia respiratory encephalopathy inflammatory vascular diseases Vitamin deficiency B12 or folate deficiency drugs and toxins sarcoidosis hepato-lenticular degeneration
Cardio-respiratory
Autoimmune
Neurological
Others
Endocrine
Taking a history
Both the patient and his or her relatives should be interviewed. Early manifestations of dementia may include changes in behaviour, e.g. excessive orderliness, interpersonal withdrawal, labile mood, sudden outbursts of anger, apathy, deterioration in grooming, telling silly jokes or suspiciousness and paranoia. Sufferers may complain of the problems themselves, or they may deny or try to rationalise them.
Differential diagnosis
Exclude any treatable cause of dementia. In delirium, there is an altered level of consciousness and a disturbance in attention and concentration.The onset is usually acute and cognitive impairment often fluctuates throughout the day. In the elderly, severe mental illness can present with apparent cognitive deficits (e.g. depressive pseudodementia).
In contrast to dementia, delirium generally has an acute onset and is characterised by an altered or fluctuating level of consciousness. Complications
Some complications of dementia are listed in Table 17-3.
Prognosis
The course depends on the cause. A dementia secondary to neurosyphilis, for example, should gradually improve with treatment. In Alzheimers Disease there tends to be a steady decline. The course for vascular dementia is sometimes described in textbooks as having a step-wise deterioration, but is in fact quite variable.
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Treatment
Family counselling The burden of care of people suffering dementia falls largely on the family, especially in the early stages. Emotional reactions include frustration with the persons behaviour, grief and sadness over the loss of the person they knew, anxiety that he or she may come to harm, and conflict among family members over what is best for the person. Educating the family about the nature of the illness, its signs and symptoms, its prognosis, and the available supports will help alleviate some of these reactions and enable the family to make informed decisions about future care. Many of the interventions discussed below require family involvement or are directed at minimising the burden of care. Families and other carers should be made aware of local support groups.
Complications of dementia include delirium (including drug-induced delirium), physical illness, depression and psychotic symptoms.
4. Psychotropic medication may sometimes be indicated for treating co-morbid illness. Doses of psychotropics should be kept as low as possible (e.g. haloperidol 0.250.5mg/ day, risperidone 0.51mg/day, olanzapine 2.55mg/day). However, higher doses are sometimes required. Excessive sedation can exacerbate confusion. Anticholinergic effects can lead to delirium. Parkinsonian side effects can cause falls. Long-acting benzodiazepines should be used with caution because of their tendency to accumulate and affect balance and coordination, leading to falls and fractures. Many psychotropic drugs have significant anticholinergic effects. Particular care is required when such medications are combined. Anticholinergic delirium is a serious complication.
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Drugs with anti-cholinergic side effects should be used with caution in people with dementia because of the risk of causing delirium.
5. Treatment of cognitive impairment Younger sufferers, who are living at home and suffer mild to moderate symptoms, may benefit from treatment with an anti-cholinesterase inhibitor. Though these drugs do not alter the progression of the disease, in clinical trials people treated with anticholinesterase inhibitors showed less deterioration in cognitive functioning than those on placebo. Two drugs are presently approved for the treatment of the cognitive impairment of dementia donepezil and tacrine. Since donepezil has little effect on butyrylcholinesterase, it is thought to be selective for CNS sites. Its long half-life permits once daily dosing. Recommended doses are between 5 and 10 mg per day. Unlike tacrine, it is generally well tolerated and does not cause hepatic toxicity. Side effects (including nausea, diarrhoea, insomnia, vomiting and loss of appetite) tend to be mild and often resolve over the first weeks of therapy. Recommended doses of tacrine (tetrahydroaminoacridine,THA) are between 10 and 40mg a day. The short half-life means that it must be administered four times a day. Fortnightly liver function tests are required over the first four weeks to monitor for elevations in alanine transaminase. Monitoring is then required monthly for three months, and every three months for the duration of treatment. Full blood examinations are required every six weeks for the first six months of treatment, and then every three months. Gastrointestinal side effects (nausea, vomiting and diarrhoea) may be troublesome and often lead to cessation of treatment. Since there is no evidence for the efficacy of these drugs in severe dementia, they should be ceased when the illness progresses to this stage1. Other drugs under investigation include SB 202026 and milameline (muscarinic partial agonists), non-steroidal antiinflammatories, oestrogen, nicotine,Vitamin E and selegiline (a Monoamine Oxidase Type B Inhibitor)2. Use community supports These include the Alzheimers Association, Dementia Helpline and ARAFMI (Association for the Relatives and Friends of the Mentally Ill). Contact your local community health service for assistance with the following: home help meals on wheels community nursing information about other agencies respite (including in-home respite, day centres and residential respite for when the family is on holiday) assessment by the Aged Care Assessment Team information about support groups for carers.
Victorian Medical Postgraduate Foundation Therapeutics Committee. Psychotropic Drug Guidelines 3rd ed. North Melbourne:Victorian Medical Postgraduate Foundation Therapeutics Committee, 1995.
Byrne GJA. Treatment of Cognitive Impairment in Alzheimers Disease. The Australian Journal of Hospital Pharmacy 1998; 28:261-266.
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Organising finances Testamentary capacity While the person still retains testamentary capacity, he or she should be encouraged to make out a will. The assessment of whether a person retains this capacity depends on his or her ability to understand the nature and purpose of a will, to have a broad understanding of his or her financial assets, and to be able to name the people who might legitimately have a claim to assets in the will. He or she must be free of delusions that might directly influence the content of the will and must be under no undue influence from others on the disbursement of his or her assets. Enduring power of attorney The following discussion refers to current Queensland law. You need to be familiar with the laws in your state/territory. A person must be able to understand the contract granting power of attorney. It enables him or her (the principal) to grant an enduring power of attorney to a named individual or individuals (the attorneys). The date or occasion upon which the power of attorney becomes activated is specified on the form. The power of attorney is enduring because it continues when the person loses the capacity to make decisions. Under the Queensland Powers of Attorney Act 1998, an Enduring Power of Attorney can authorise the attorney to make both financial and health care decisions on behalf of the other person. If you become aware of problems in the way an attorney is managing a persons affairs, you should notify the Adult Guardian (phone 07 32340870 or 1300 653 187). Forms are available from newsagencies, GoPrint bookshops, Commonwealth Government Bookshops and legal stationers. The Public Trustee In Queensland, if a person who has not appointed an enduring power of attorney becomes incapable of managing his or her financial affairs, the Adult Guardian should be contacted. The Adult Guardian will then arrange for the Public Trustee to manage the persons financial affairs. Consent for medical procedures This matter is dealt with by different laws in each state/territory. The Queensland Powers of Attorney Act of 1998 defines the ways in which health care decisions can be made on behalf of people whose decision-making capacity is impaired. Advance health directive This document allows the individual to give general instructions about his/her future health care, including end-of-life decisions, such as refusal of life-sustaining medical treatment, if he or she is terminally ill. In Queensland, this does not include instructions for a doctor to help a person die. Enduring power of attorney As mentioned above, a person (the principal) can appoint another (the attorney) to make future health care decisions on his or her behalf if at some time in the future the principal loses the capacity to make such decisions. Statutory Health Attorney In the case of a person who develops a decision making disability, but has not appointed an enduring Power of Attorney, the Queensland Act makes provision for a close relative or carer who is readily available and could be expected to take responsibility to be able to make health care decisions on his or her behalf. The Statutory Health Attorney is appointed by the Adult Guardian. If no suitable person is available, the Adult Guardian can make these decisions. This replaces the previous informal practice of having the next-of-kin make these decisions. Work Repetitive tasks may remain within the capacity of someone with early dementia. Jobs that carry responsibility for others, include an element of risk and require clear judgment, must be discontinued.
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Education Explain the prognosis of the condition to patients, their families and other carers. In deciding how explicit to be, it is best to be guided by the individuals questions. Relatives will often want a clear description of the prognosis so that decisions affecting the long-term interests of the family can be made. Families may be reassured to know that a persons distress over his or her impairment tends to lessen with the progress of the condition.
Relatives of people with dementia need a clear description of the prognosis so that decisions affecting the long-term interests of the family can be made.
Disability support This involves decreasing the need for functions lost while maximising the use of residual functions. Some advice for carers is contained in Table 17-4.
Driving Medical practitioners have a responsibility to notify the Department of Transport if, as a consequence of a medical condition, a person may be unfit to drive. Other family members are often good witnesses as to the persons driving ability. If you are unsure, refer the person for a driving test. Living situation Plans are best made well in advance if it is anticipated that the person will need to move to a hostel, retirement village or a nursing home. In Queensland, the local Aged Care Assessment Team (ACAT) carries out the assessment of suitable placement.
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Any disease or substance that affects the central nervous system can cause mental symptoms, including depression, anxiety, personality change and psychosis. Table 17-5: Physical disorders that can cause depression
neurological disorders: Parkinsons disease Huntingtons disease dementia cerebrovascular accident epilepsy multiple sclerosis traumatic brain injury hyper- and hypothyroidism hyper- and hypoparathyroidism Cushings disease Addisons disease systemic lupus erythematosus rheumatoid arthritis influenza hepatitis infectious mononucleosis HIV infection pneumonia tuberculosis tertiary syphilis especially cancer of the pancreas B12, C, folate, thiamine
endocrine disease:
Intoxication or withdrawal from a variety of substances can lead to the development of psychological symptoms. A list of drugs that can cause depression is given in Table 17-7. Drugs that can cause anxiety are listed in Table 17-8. Alcohol abuse can be complicated by the development of psychotic symptoms, depression or anxiety during intoxication or withdrawal. Amphetamines and cocaine can cause psychotic symptoms during intoxication, and depression and anxiety during both intoxication and withdrawal. The use of marijuana can cause psychotic symptoms and anxiety during intoxication. Benzodiazepines can cause psychosis and depression during intoxication and anxiety during withdrawal.
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endocrine disease:
cardiovascular conditions:
respiratory disorders:
metabolic disorders:
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benzodiazepines (withdrawal)
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Chapter 18
Substance abuse
Substance abuse is a common presentation in general practice.Around 13 per cent of adults abuse alcohol at some time in their lives with between three and five per cent of men and one per cent of women becoming alcohol dependent. Alcohol is a contributing factor in around 50 per cent of motor vehicle fatalities, 50 per cent of homicides and 25 per cent of suicides. Illicit drug use is most prevalent among young people, especially young men.The assessment of substance abuse is complicated by the fact that few sufferers will present with the problem directly.
Assessment
1. Screening People with substance abuse often deny their problem. Do not hesitate to ask. A useful screening test for alcohol abuse is the CAGE questionnaire. Two or more positive answers are correlated with alcohol dependence in over 90 per cent of cases. C Have you ever thought you should CUT DOWN on your drinking? A Have you ever felt ANNOYED by others criticism of your drinking? G Have you ever felt GUILTY about your drinking? E Do you have a morning EYE OPENER? Take particular care in assessing people who do not fit the stereotype of a substance abuser, e.g. a woman with panic disorder and agoraphobia. Substance abuse is common in this group. People may be secretive about their substance abuse.
The CAGE questionnaire is a useful screening instrument for detecting alcohol abuse.
2. Reason for presentation People commonly present with unrelated problems, or with physical or psychological complications of the substance abuse. They may be motivated to do something about their problems because of the threat of job loss, marital breakdown or legal difficulties. 3. Extent and pattern of abuse Document the amount of the substance consumed, the time course of the problem and the pattern of abuse. For example, the amount of alcohol consumed should be quantified in terms of the number of standard drinks per day. A standard drink is equivalent to a 200ml glass of beer, a 90ml glass of wine or a 30ml glass of spirits. A small bottle of beer is equivalent to 1 standard drinks, a large bottle to 3. A bottle of wine is equivalent to eight standard drinks. Recommended safe maximum daily quantities are four standard drinks for men and two for women. Patterns of drinking vary between different populations. For example, Anglo-Saxons typically binge drink, while those from continental Europe more often drink steadily. Ask if the person has suffered any symptoms of withdrawal and whether he or she requires larger amounts to get the same effect (tolerance). Try to uncover the precipitants of the substance abuse. Drinking binges typically occur at times of stress. Identifying the emotional state that leads people to abuse substances is often complicated by their inability to identify and describe feelings (alexithymia).The alexithymic person is prone to act out in
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order to modulate unpleasant affects, rather than to recognise and articulate how he or she feels. 4. Disability and handicap Ask about the social consequences of the substance abuseloss of employment, legal problems (e.g. driving under the influence, charges for possession of illicit substances), marital and family problems and financial problems. Assess the amount of time spent obtaining, taking or recovering from the substances abused (salience), and about activities that have been given up or reduced as a consequence of the abuse. 5. Past treatments Document previous treatments that were most effective for that individual. 6. Co-morbidity The physical and mental health problems associated with the abuse of specific substances are discussed below. 7. Mental state examination Assess for the substance-specific effects of intoxication and withdrawal and, where applicable, complications of abusedelirium, dementia, psychosis, anxiety or depression. 8. Physical examination and investigations Assess the substance-specific physical complications discussed below.
Diagnosis
The DSM-IV criteria for substance dependence include a pattern of substance use that results in significant impairment, disability and handicap, and includes at least three of the following: tolerance (i.e. increased amounts of the substance required to achieve the same effect, or less effect with the same amount); withdrawal, or taking substances to avoid withdrawal symptoms; larger amounts taken than intended; repeated unsuccessful attempts to cut down; a lot of time spent obtaining, using or recovering from the effects of the substance; abandoning important social, occupational, or recreational activities because of the substance abuse; or continued use of the substance despite knowledge of having a persistent physical or psychological illness that is caused or exacerbated by it1. The DSM-IV also includes the category, substance abuse, for those cases in which problems exist, but the criteria for dependence are not met. This diagnosis requires the continued use of substances in situations that are hazardous (e.g. drink-driving) or that result in significant physical or mental health problems, disability or handicap. The abuse of substances is associated with specific syndromes of intoxication and withdrawal. Some may cause psychological symptomsdelusions, hallucinations, depression or anxiety. Complications include delirium and dementia. Hallucinogens can cause flashbacks.
Formulation
The formulation will help you tailor treatment to the individual patient. Biological factors Family studies have demonstrated a strong genetic contribution to the development of alcohol abuse. Monozygotic twins have around twice the concordance rate as do dizygotic twins. The offspring of alcoholics have around four times the chance of developing alcoholism as do the children of non-alcoholics, even when raised apart form their families of origin. This biological predisposition provides some evidence for the formulation of alcoholism as a disease, a central tenet of the beliefs underlying Alcoholics Anonymous. However, the incomplete concordance in monozygotic twins is evidence that environmental factors also play a part.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington DC: American Psychiatric Association, 1994.
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Substance abuse
Psychological factors People may use substances for their pleasurable effects or to avoid some emotional pain. In some cases, people use substances to cope with the psychological symptoms of depression and anxiety. Unfortunately, the use of substances, while alleviating symptoms during intoxication, may worsen them in the long-term.
People may abuse substances in an attempt to treat their mental disorders. These often exacerbate the symptoms.
Mental disorders associated with substance abuse include anxiety, depression and antisocial personality disorder. The rate of suicide among alcoholics has been estimated to be between 60 and 120 times the rate among non-alcoholics. Alcohol use is a contributing factor in as many as 25 per cent of completed suicides. Co-morbidity rates among the abusers of illicit drugs have been calculated to be 53 per cent, a rate higher than that for alcoholics (37 per cent).
Mental disorders that are commonly associated with substance abuse include anxiety, depression and antisocial personality disorder.
The psychodynamics of substance abuse suggest that people may abuse drugs to deal with problems in self-esteem and to assist in the modulation of unpleasant affects (anxiety, depression, shame, guilt and rage). These disorders reflect problems in impulse control that may be manifest in other aspects of the persons behaviour such as criminality, self-harm and violence. Substance abuse can be a form of acting out. People may use substances to suppress or remove unpleasant affective states instead of identifying and articulating how they feel, and taking steps to deal with the problems that give rise to these feelings. People sometimes use substances in response to problems in their interpersonal relationships. Social factors Substance abuse may occur in response to social stressors. The abuse of illicit drugs is often complicated by criminal behaviour required to obtain the substances. The prevalence of abuse increases with ready access to the drug. Peer pressure in often a factor, especially in young people experimenting with drugs. The use of some substances is glamorised in the media and in advertising. Certain professions are at high risk. For example, bartenders, journalists, musicians, writers and doctors have higher rates of alcohol abuse than others. Young, single, unemployed youth from socially deprived backgrounds are at relatively high risk of opiate abuse.
Treatment
The principles of treatment include the following: 1. Therapeutic alliance Be aware of countertransference responses of anger and helplessness. Substance abusers have often been met by hostility and rejection in the past. Convey your concern about the problem, but be careful neither to judge nor try to take responsibility for it. It is often useful to acknowledge that you are powerless to stop a person abusing substances.You cannot stop a young man who abuses illicit drugs from obtaining the substances, nor can you stop an alcoholic from going to the pub. Within a strong therapeutic alliance, you will be able to confront people about their substance abuse without alienating them. 2. Care in prescribing General practitioners often face demands to prescribe or administer therapeutic drugs. For locum doctors attending people in their homes, this can also be dangerous. Have a high index of suspicion of people who ask for opiates or benzodiazepines, especially those who
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have not consulted you before. If in doubt, you may prescribe small quantities of the drug. Suspected addicts should be reported to state health authorities. In the absence of legitimate indications, you should calmly, but firmly, refuse to prescribe the drug. 3. Education Educate the person and his or her family about the effects of intoxication and withdrawal, and the physical and mental disorders that may complicate abuse of the substance. Outline the treatment options available, including the relevant drug and alcohol dependency agencies, non-government organisations and self-help groups. 4. Diagnosis and treatment of co-morbid physical and mental disorders The assessment of whether psychological symptoms are caused by the substance abuse or are evidence of a co-morbid condition is often difficult. Consider the symptoms of intoxication and withdrawal for the specific substance involved. Generally, withdrawal symptoms will resolve after two to four weeks. Persistence of symptoms beyond this period suggests the presence of a separate condition. 5. Treatment of the psychosocial complications of abuse Issues that all substance abusers have to face are the losses associated with their habit. These include losses of physical health, work opportunities, family, friends and finances. Unfortunately, identifying the stressors that precipitate abuse is often difficult because of the tendency for substance abusers to deny both their abuse and their other problems. The principles of counselling and structured problem solving described in Chapter 6 can be used to help deal with these losses and with other stressors. 6. Self-help groups Alcoholics Anonymous (AA) is a self-help organisation that was set up in the USA after the lifting of prohibition in 1937. It is based on the belief that alcoholism in a disease over which the sufferer has no control. Members are taught that they need to submit to a higher power in order to maintain abstinence. In the meetings, sufferers give testimonies of their problems and provide mutual support. Although very effective for some, AA tends to have less appeal for young people, women and members of minority groups. Others have difficulty accepting the ideology of the organisation. Ancillary groups exist for the families of sufferers (Al-ATeen and Al Anon). Similar groups exist for those who abuse other substances (e.g. Narcotics Anonymous). However, these have generally been less successful, in part because of the different age group and subculture affected. 7. Family work Substance abuse invariably affects the spouses, families and others close to the person.The loss of social supports is an important perpetuating factor in the illness. The reactions of family members may inadvertently reinforce the substance abuse. Family members may themselves suffer psychological problems as a result of a persons substance abuse. Both the patient and family members must acknowledge that abstinence is ultimately the responsibility of the patient. No matter how concerned someone else might be, he or she cannot stop another adult from obtaining and abusing drugs (see Box 18-1).
Both the patient and family members must acknowledge that abstinence is ultimately the responsibility of the patient. Box 18-1: Abstinence is the patients responsibility
A 55-year-old man who suffers alcohol dependence presents with his wife. He complains that she has not been vigilant enough recently in monitoring his drinking. Last week he went on a three-day drinking binge and she did nothing about it. The man is projecting responsibility for his problem on to his wife. She is made to feel how powerless he feels in trying to overcome his problem. In such a case, you would be concerned about her welfare, including her safety.
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8. Abstinence or controlled use Whether the goal is abstinence or controlled use will depend on the substance used and the individual concerned. Abstinence is recommended during pregnancy, in cases of polysubstance abuse, when there are serious physical or mental complications of the abuse, when previous attempts at controlled use have failed, or when there is significant disability and handicap.
Abstinence, as opposed to controlled use, is advised in the following: during pregnancy, in cases of poly-substance abuse, when there are serious complications of abuse, when previous attempts at controlled use have failed, and when there is significant disability and handicap.
Alcohol
Forty per cent of those who abuse alcohol have a good outcome, 47 per cent continue to abuse and the remainder have a fair to poor outcome. Unfortunately, the impact of treatment is sometimes modest with 19 per cent improving spontaneously over a 12-month period and 26 per cent improving with treatment1. Predictors of a good outcome include finding a substitute for the dependency (e.g. devotion to work, a consuming interest or hobby, or membership of a cohesive religious or therapeutic group such as AA); a serious threat to ones physical health, marital and family relationships or career; legal problems; or a new relationship. Consider the following in the treatment of a person with alcohol withdrawal: 1. Place the person in a well-lit room. Monitoring vital signs and mental status will guide the doses of diazepam administered and the supportive measures required to maintain fluid and electrolyte balance. Investigations may include electrolytes and liver function tests, full blood examination and clotting studies. A chest X-ray may be indicated if there are signs of infection. A CT scan of the head may be needed if there is any evidence of head trauma. 2. Administration of diazepam until calm with a tapering dose over the next seven to 14 days; Thiamine 100mg intramuscularly daily for three to five days, then 100mg orally, daily with vitamin B complex. These are continued over the following months to prevent the development of Wernickes encephalopathy (see following).
During alcohol withdrawal, thiamine and vitamin B complex are given to prevent the development of Wernickes encephalopathy.
3. Supportive measures to maintain fluid and electrolyte balance, to guard against aspiration, and to avoid hypoglycaemia. 4. The treatment of co-morbid conditions, including possible closed head injury, Wernickes encephalopathy, infections, acute liver and cardiac problems, and seizures. The physical complications of alcohol abuse include gastritis, peptic ulcer, pancreatitis, liver disease, diarrhoea, hypertension, trauma, impotence, insomnia, peripheral neuropathy, cerebellar degeneration and cardiomyopathy. Alcohol abuse is also associated with a number of mental
Parloff MB, London P, Wolfe B. Individual psychotherapy and behavior change. Annual Review of Psychology 1986; 37: 321-349.
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disorders. A failure to diagnose and treat these disorders will prevent adequate treatment of the substance abuse: 1. anxiety disorders These are the commonest mental disorders found in association with alcohol abuse. The symptoms of alcohol withdrawal include anxiety and panic attacks. People with phobias or post-traumatic stress disorder may self-medicate with alcohol. 2. depression Alcohol can cause or exacerbate depression. In some cases, a person may drink in order to alleviate symptoms of depression. 3. suicide The suicide rate among alcoholics is between 50 and 120 times that for the rest of the population. Alcohol is a contributing factor in around 25 per cent of suicides. 4. psychosis Alcohol may interact with antipsychotic medications and lead to behavioural problems in those with psychotic illnesses. Alcohol hallucinosis usually arises during withdrawal and is characterised by auditory hallucinations that persist after the physical withdrawal. People with alcohol hallucinosis should be carefully assessed for suicidality and dangerousness. 5. neuropsychiatric disorders Wernickes encephalopathy is a medical emergency. It is an acute brain syndrome that is characterised by delirium, confusion, ataxia, bilateral symmetrical ophthalmoplegia especially affecting the sixth cranial nerve, and nystagmus. It is caused by thiamine deficiency that is often associated with alcohol abuse.Treatment includes thiamine 100mg intramuscularly and oral vitamin B complex over the following months. If left untreated, this condition may progress to Korsakoff s Psychosis.The syndrome includes short-term memory deficits, confabulation, polyneuropathy and disturbed eye movements (including lateral nystagmus and paralysis of conjugate gaze). Alcohol abuse can also be associated with the development of dementia.
6. foetal alcohol syndrome The child may suffer mental retardation and various anatomical abnormalities (cleft palate, microcephaly and hypospadias).
Alcohol abuse is associated with anxiety disorders, depression, suicide, psychosis, neuropsychiatric conditions (including Wernickes encephalopathy, Korsakoffs Psychosis, dementia and foetal alcohol syndrome).
Disulfiram is sometimes used as an aversive measure in the treatment of chronic alcoholism. It should be prescribed to physically fit, highly motivated people with a good record of adherence to treatment who are involved in a structured therapeutic program that includes regular checks on adherence. In view of the serious interactions with alcohol, I recommend referral to a specialist unit if this treatment seems indicated.
Opiates
Psychological symptoms of opiate intoxication include euphoria, drowsiness and sometimes, anxiety. Physical signs include pupillary constriction, slurred speech, respiratory depression, hypotension, nausea, vomiting and constipation. Opiate overdose can cause death through respiratory depression and pulmonary oedema. Treatment involves monitoring, support and the administration of intravenous naloxone.
The treatment of opiate intoxication includes monitoring, general supportive measures and the administration of naloxone.
Opiate withdrawal is usually managed in a specialised inpatient facility. Symptoms of withdrawal include nausea, abdominal cramps, muscle aches, sweating, gooseflesh, restlessness, lacrimation, nasal congestion and tachycardia. Physical complications of chronic opiate use include overdose,
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malnutrition, HIV infection, hepatitis and other infections. Associated psychological problems include depression, anxiety and antisocial personality disorder. Efforts to obtain the drugs may lead to criminality and prostitution. Criteria for methadone maintenance include prolonged physiological dependence on opiates, pregnancy, or failed attempts at drug detoxification. The aim is to reduce the craving for heroin use, prevent the complications of intravenous drug use and permit rehabilitation. It can also limit criminal behaviour associated with drug seeking. Longer-term residential programs provide drug-free environments in which rehabilitation can occur.
Criteria for methadone maintenance include prolonged physiological dependence on opiates, pregnancy, or failed attempts at detoxification. Cannabis
Cannabis is used as either leaves (marijuana) or resin (hashish) that are either smoked or eaten. The principal active agent is delta-9-tetrahydrocannabinol (THC). Complications of intoxication with cannabis include anxiety, derealisation and acute paranoid states. It may hasten relapse in people with psychotic disorders. There is no conclusive evidence that it causes psychosis, but there is anecdotal evidence that the use of cannabis can precipitate a first episode and worsen the prognosis.
Stimulants
Amphetamines may be taken orally, intravenously or by nasal ingestion. Cocaine is usually taken nasally or smoked. Intoxication can be complicated by seizures, myocardial infarction, cerebrovascular accident, damage to the foetus and nasal ulceration. Adverse psychological reactions include manic-like symptoms, anxiety, paranoia, aggression and poor judgement. Treatment of intoxication may require antipsychotic medication, support and protection. Withdrawal symptoms include depression, suicidality, fatigue, insomnia and irritability.
Hallucinogens
The common hallucinogens include lysergic acid diethylamide (LSD), psylocibin (in magic mushrooms) and methylenedioxymethamphetamine (MDMA, also known as ecstasy). Adverse reactions include anxiety, depersonalisation, derealisation, depression, illusions, hallucinations, delusions, risk-taking behaviour and flashbacks. Treatment involves sedation with diazepam and sometimes haloperidol. Chlorpromazine can sometimes cause a paradoxical reaction with increased anxiety.
Solvents
Common inhaled agents include petrol, glues, lighter fluids and nitrous oxide.The abuse of these substances is most prevalent among young people, especially those in low socioeconomic groups. Adverse effects include confusion, disorientation, impulsive behaviour, ataxia, psychosis, seizures and coma. Death can result from respiratory depression, asphyxiation and cardiac arrest. Longterm use of solvents can cause damage to the cerebellum, liver, kidneys and bone marrow.
Hypnotics
The commonest hypnotics abused these days are benzodiazepines, although barbiturate abuse is still occasionally seen. Among the benzodiazepines, the commonest abused drugs are the more potent ones such as flunitrazepam and alprazolam. The effects of intoxication and withdrawal are similar to those for alcohol. Symptoms and signs of intoxication include drowsiness, confusion, disinhibition, slurred speech, ataxia, poor coordination and nystagmus. Fatalities can occur from respiratory depression or inhalation of gastric contents. Symptoms of withdrawal
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include anxiety, tremor, sweating, irritability and insomnia. Delirium can occur with visual hallucinations and formication. Seizures and coma may complicate withdrawal. Prevention is the cornerstone of treatment. Educate patients about the dangers of tolerance, dependence and withdrawal. In particular, advise them of the danger of withdrawal seizures. Prescribe only small quantities over short periods of time. Treatment of withdrawal involves close monitoring of mental state and vital signs while a long-acting benzodiazepine such as diazepam is administered in gradually diminishing doses. For the older person who has been dependent on a small dose of a benzodiazepine or barbiturate for many years, it is sometimes best to continue the drug at the current dose.
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Chapter 19
Somatoform disorders
People often present to general practitioners with physical symptoms for which no organic cause can be found, or which are in excess of what would be expected from a physical disorder that is present. The prevalence among general practice attendees has been estimated to be between 25 and 50 per cent. The presentations fall into three groups: unexplained physical symptoms, hypochondriasis, and mental disorders presenting with somatic symptoms. In one study, the prevalence of these conditions among general practice attendees was found to be 16.6 per cent, 7.7 per cent and 8 per cent1 respectively.
Between 20 and 50 per cent of general practice attendees present with physical symptoms for which no organic cause can be found.
A failure to diagnose and treat these conditions will have a number of adverse consequences. The person will continue to suffer symptoms, disability and handicap.Treatable mental disorders will be missed. Unnecessary investigations and unwarranted treatments are costly and can lead to further disability. Excessive specialist referrals are expensive and will reinforce the persons conviction that there is something physically treatable that continues to elude diagnosis. The dissatisfied patient is likely to seek help from other doctors. I begin this chapter with a discussion of the assessment of the somatoform disorders in general. I then discuss the treatment of unexplained physical symptoms and hypochondriasis.Although the prolonged fatigue syndromes fall within the category of unexplained physical symptoms, I include a separate discussion of their treatment because of their high prevalence in general practice settings.
Assessment
People with somatoform disorders are difficult to assess. They are often frustrated with their previous medical advice and unwilling to consider psychological contributions to their suffering. Consider the following steps in the assessment:
Interview techniques
The approach you take in the interview and in subsequent treatment will depend on the ability of the person to accept the contribution of psychological factors to the problem. Some people
Kirmayer LJ, Robbins JM. Three forms of somatization in primary care: prevalence, co-occurrence, and sociodemographic characteristics. The Journal of Nervous and Mental Disease 1991; 179: 647-655.
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will readily do so and engage in psychological treatments. Others will, to varying degrees, resist such an explanation, insisting that you must find and treat a physical cause.
Some people readily accept the contribution of psychological factors to their problems. Others resist such an explanation and insist that you find a physical cause.
Goldberg and others have proposed a three-stage model for helping people with unexplained physical symptoms to re-attribute their symptoms and relate them to psychosocial problems1. The first step involves making the person feel understood. Give the person time to describe his or her complaints. Take a full history of the symptoms, their time course and any precipitants. Ask about the symptoms occurrence over a typical day. Respond to verbal and nonverbal cues by making empathic comments (The pain sounds very severe, or You must get fed up when doctors cannot get rid of the pain), clarifying (Tell me when the pain first began) and asking about the mood (How did that make you feel?). Establish a picture of the family and social context in which the symptoms have arisen. Ask what the person believes the symptoms mean. Perform a brief physical examination. The second stage involves changing the agenda to incorporate complaints other than the physical symptoms. Summarise the physical findings. Acknowledge the reality of the symptoms and the distress that they cause. Reframe the problems incorporating other symptoms and relating their onset to stressors in the persons life. It may be useful to ask the patient to record the situations in which symptoms were worse during the week, what they were doing at the time, where and with whom they were. The final stage involves making an explicit link between the persons emotional state and the physical symptoms. When the symptoms are related to anxiety, explain the pathophysiological process responsible for causing the symptoms, for example, When people get very anxious, they often over-breathe. This causes a number of changes in the ability of blood to carry oxygen to the brain that can make you feel dizzy, sweaty and cause tingling in your hands and around your mouth. A similar approach is used for depressionWhen people are depressed their pain threshold is altered so they tend to be more sensitive to pain. Discuss the other symptoms that the person suffers that are typical of the underlying mental disorder. It may be useful to demonstrate how muscular tension can cause muscle aches and pains by, for example, asking the person to hold a book with his or her arms outstretched. Link the onset and exacerbation of symptoms to stressful events in the persons life. It may be useful to ask the patient to record the situations in which symptoms were worse during the week, what they were doing at the time, and where and with whom they were. Ask how the person is feeling presently, in the consultation, and relate this to his or her worries about what the symptoms mean. Ask if any other family member has suffered similar symptoms and discuss possible psychological contributions to this it is often easier for the person to see the links between physical symptoms and stressful events or psychological problems in someone else. Having completed the assessment, you should now be in a position to negotiate treatment.
A three-stage model for helping patients reattribute their somatic symptoms to psychological as well as physical causes includes making the person feel understood, changing the agenda to incorporate complaints other than physical symptoms, and making explicit links between his or her emotional state and the physical symptoms.
Goldberg D, Gask L, ODowd T. The treatment of somatization: teaching techniques of reattribution. Journal of Psychosomatic Research 1989; 33:689-695.
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In most cases of unexplained physical symptoms, there is some underlying physical disorder, but the symptoms are in excess of what would be expected. Presentation
These disorders are characterised by the presence of one or more physical symptoms for which there is either no medical explanation or the amount of impairment, disability and handicap is greater than what would be expected from the physical pathology that is present. Common symptoms include pain (e.g. headaches, abdominal pain), gastrointestinal symptoms (e.g. constipation and diarrhoea), sexual symptoms (e.g. erectile or ejaculatory dysfunction, irregular periods or excessive menstrual bleeding), pseudo-neurological symptoms (e.g. dizziness, incoordination, poor balance, localised weakness, urinary retention, sensory changes, seizures or amnesia) or fatigue. People with unexplained pain tend to make frequent medical consultations, often to different doctors, and fail to be reassured about the nature of their symptoms.
Diagnosis
Specific disorders include somatisation disorder, conversion disorder, pain disorder and the prolonged fatigue syndromes. Somatisation is a chronic disorder that requires the presence of at least eight symptoms (four of pain, two gastrointestinal, one sexual and one pseudoneurological), beginning before the age of 30 years1. While the prevalence of this disorder is low (between 0.2 per cent and 2 per cent), the presentation of a part-syndrome is very commonbetween 9 and 20 per cent in community samples). The essential feature of conversion disorder is the presence of symptoms or deficits affecting voluntary motor or sensory function that cannot be fully explained by a general medical condition or the effects of a substance. Psychological factors are seen to play a part in the onset or exacerbation of the symptoms. In pain disorder, the predominant complaint is of pain, in which psychological factors are judged to have an important role in the onset, severity, exacerbation or maintenance. The prolonged fatigue syndromes are discussed below.
The syndromes of unexplained physical symptoms include somatisation disorder, conversion disorder, chronic pain and the prolonged fatigue syndromes.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Association, 1994.
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Differential diagnosis
Unexplained physical symptoms often arise in the context of other mental disorders. People with depression may suffer fatigue, loss of energy, restlessness, poor appetite and weight loss (see Chapter 14). Anxiety is accompanied by a wide variety of physical symptoms, including muscle tension, fatigue, shortness of breath, palpitations, chest pain, nausea, abdominal distress, dizziness, paraesthesia, derealisation and depersonalisation (see Chapter 15). The perception of physical symptoms is altered in several mental disorders: the anxious or depressed person is likely to focus on the pain, which in turn makes it worse. People suffering from schizophrenia may describe bizarre physical complaints (see Chapter 22).
Formulation
Biological factors Unexplained physical symptoms may arise in the absence of any clear physical pathology. However, more often there is an underlying physical problem, but the symptoms are more distressing and produce greater disability than would be expected. Chronic conditions can be complicated by the effects of inactivity, self-medication with alcohol and other substances, and the iatrogenic complications of prescribed medications, multiple investigations and procedures. The perception of pain depends not only on the extent and site of physical injury, but also on the modulation of neural information by gating mechanisms in the dorsal horns of the spinal cord. Inputs from higher cortical and subcortical areas are integrated with inputs from peripheral afferent fibres to modulate the perception of pain.This may explain the impact of emotional states on pain perception and the efficacy of relaxation techniques, cognitive behavioural approaches, distraction and hypnosis in treatment. Psychosocial factors The symptoms can often be understood in terms of the persons past history. For example, a man may identify with a parent who, during his childhood, suffered chronic illness. A woman who was emotionally neglected in childhood may have learnt that the only way she could obtain support and nurturance was through being sick.The person who was traumatised as a child may have an unconscious need to continue suffering and to be punished. The persons current social milieu may reinforce his or her abnormal illness behaviour. By adopting the sick role, a person is exempted from his or her normal duties and responsibilities and may gain attention and support from family members. In doing so, they reinforce the behaviour. At the same time, the person may covertly express his or her anger with other family members. Compensation and other legal issues may also play a part in reinforcing the abnormal illness behaviour. In some cases, the problem may lie with someone else in the persons social system (see Box 19-1).
The persons social milieu may reinforce his or her abnormal illness behaviour.
Box 19-1: When the problem is not with the person who presents
An 87-year-old woman who suffers from early dementia is brought to you repeatedly by her 90-yearold husband because of abdominal pain. She has been admitted to the local hospital on several occasions, but no physical cause for her symptoms can be found. Her husband is upset that the hospital will not admit her on this occasion, and he asks you to arrange the admission. An exclusive focus on the womans presenting symptoms may lead you to miss the primary problemher husbands inability to cope. Treatment will include forming a therapeutic alliance with both the woman and her husband and maximising his social supports to alleviate the burden of care.
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Treatment
It is useful to consider two groups of patientsthose who present occasionally with physical symptoms, usually when under stress, and those with chronic unexplained physical symptoms. Members of the first group are often quite willing to acknowledge a psychological cause for their symptoms. They will be reassured by an explanation of how stress can produce the presenting symptoms. Having clarified the stressors facing the individual, structured problem solving can be used to help the person deal with them (see Chapter 6).
Counselling and structured problem solving will assist people to deal effectively with stressful events in their lives.
People with chronic unexplained physical symptoms are amongst general practitioners most challenging patients. Consider the following principles of treatment1: 1. Medical examination is required to uncover any physical cause for the symptoms. The results of the examination and any investigations should be carefully explained to the person. The ways in which emotional states can modulate the perception of pain should also be explained. On repeat visits, new symptoms should be noted and a focused physical examination performed. 2. Avoid excessive investigations and procedures. Make regular, time-limited appointments. Dissuade the person from consulting different doctors for the same problems. Only refer to a specialist if there is clear evidence of serious physical disorder.
Avoid excessive investigations, procedures and specialist referrals when treating people with unexplained physical symptoms.
3. Diagnose and treat any primary or co-morbid mental disorders, especially depression, anxiety and substance abuse.
People with unexplained physical symptoms are at risk of developing depression, anxiety disorders and substance abuse.
4. Acknowledge the pain and explain to the patient that he or she may have to learn to live with some symptoms. Make the aim of treatment to improve the persons ability to cope with the pain, and to have a fulfilling and enjoyable life in spite of it. Concentrate on rehabilitation rather than cure. Rehabilitation activities include a graduated exercise program and setting daily activity schedules that include pleasurable activities (see the non-specific treatments for depression in Chapter 14 and Appendix 7). Teach relaxation techniques (see progressive muscular relaxation in Appendix 5 and self-hypnosis in Appendix 6).
Bass C, Benjamin S. The management of chronic somatisation. British Journal of Psychiatry 1993; 162: 472-480.
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Advise family members to acknowledge the persons symptoms, but to avoid constantly responding to them. Instead, they should give as much reinforcement and praise as possible in response to healthy coping and rehabilitation activities.
Encourage family members to avoid responding to pain behaviour but to reinforce coping behaviours.
7. Monitor your countertransference. People with unexplained physical symptoms present particular challenges for general practitioners.They will challenge your knowledge and make you feel anxious that you are missing something. You may feel exasperated by the patients symptoms and his or her failure to get better. Having a clear formulation will organise your thinking and allay your anxiety. Continuing to deepen your understanding of the problems will maintain your interest and increase your confidence in the formulation. 8. Consider referral to a psychiatrist. Be straightforward about who you are asking the person to see. The formulation and treatment of a man with pain disorder is discussed in Box 19-3.
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Hickie IB, Lloyd AR, Wakefield D. Chronic fatigue syndrome: current perspectives on evaluation and management. The Medical Journal of Australia 1995; 163:314-318. 2 Hickie I, Hadzi-Pavlovic D, Ricci C. Editorial: reviving the diagnosis of neurasthenia. Psychological Medicine 1997: 27;989-984. 3 Sharpe M, Hawton K, Simkin S et al. Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial. British Medical Journal 1996; 312:22-26. 4 Deale A, Chalder T, Marks I, Wessely S. Cognitive behavior therapy for chronic fatigue syndrome: a randomized controlled trial. American Journal of Psychiatry 1997; 154:408-414. 5 Warwick HMC, Clark DM, Cobb AM Salkovskis PM. A controlled trial of cognitive-behavioural treatment of hypochondriasis. British Journal of Psychiatry 1996; 169:189-195.
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Fatigue usually occurs in association with a psychological disorder (especially depression or anxiety), but in about a third of cases, there is no significant psychological disorder present.
There is unlikely to be a single cause of prolonged fatigue. Possibilities include chronic viral infection, immune dysfunction, neuro-endocrine disturbance and underlying depression or anxiety. What is certain is that disability and handicap may be severe. In particular, a vicious cycle is often established in which fatigue leads to avoidance of exercise and activity, which in turn leads to depression, anxiety and a worsening of the physical symptoms.
Assessment
In assessing the person with fatigue, consider possible physical and psychiatric causes (see Table 19-1). Clarify the pattern of the fatigue, whether the person is tired all of the time or only in certain situationsfor example, when at work. Does performing everyday tasks easily tire the person? Inquire about a mans lifestyle. Does he get enough sleep; does he do any regular exercise; is he over-worked; is he bored; are there any current stressors; is he angry about something? Clarify the onset of the problem. Has it been a problem for a long time; were there any precipitants? Explore his or her beliefs about the cause of the illness and try later to incorporate this in a broad, multifactorial formulation of the problem. Assess the persons level of disability and handicaphis or her self-care, family and other personal relationships, work and leisure activities.
Investigations
Investigations that may be useful include: urinalysis full blood count and differential ESR electrolytes and liver function tests blood glucose thyroid function tests sleep studies
Treatment
Since much of the disability flows from the avoidance of activity and exercise, an essential component of treatment is to expose the person through a graduated exercise program and increasing daily activities.The recommendations made in the past to rest and avoid activities will only lengthen the duration of the illness and lead to more severe disability and handicap.
An essential component of the treatment of prolonged fatigue is to expose the person to a graduated exercise program and to increase his or her daily activities.
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1. Perform appropriate medical and psychiatric evaluation to note the presence of any of the aetiological factors mentioned in Table 19-1. Avoid performing investigations and making specialist referrals unless there are clear reasons for doing so. Make regular scheduled appointments and encourage the person to consult only one doctor in order to avoid duplication of investigations, adverse drug reactions and confused communication about the nature of the problem. 2. Ask the patient to record his or her activities over a week using a daily activity schedule.This will often reveal a pattern in which bouts of vigorous or prolonged activity are followed by a worsening of fatigue symptoms, and then periods of rest and recovery. A vicious circle is established in which the link between activity and fatigue is continually reinforced. An important aim of treatment is to break this link. This is done by planning regular small amounts of exercise every day rather than sudden bursts once a week. Patients are encouraged
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to perform their planned activity even if they are feeling fatigued. On the other hand, they are advised not to perform any vigorous or more demanding activity, even if they are feeling very well. 3. Use a graduated exercise program to increase the persons exercise tolerance. This part of treatment involves exposing the person to the feared situationin this case, the normal physiological changes associated with aerobic exercise. The person learns that these changes do not represent warning signs of physical illness. Exercise also has a beneficial effect on mood. 4. Teach the patient response prevention to avoid checking behaviours (e.g. monitoring pulse rate, weight, lymph nodes etc.) and seeking reassurance. 5. Demonstrate to the patient how focusing on a particular body part can induce symptoms. 6. Use structured problem solving to deal as effectively as possible with stressors in relationships and at work (see Appendix 3). 7. Advise the person on good sleep habits (Table 14-3). People with chronic fatigue often have an inconsistent sleep pattern, sleeping during the day and then staying up late.They may stay up late over the weekend and then struggle to go to work on Monday morning. Negotiate regular times for going to bed and rising. 8. Use cognitive behavioural techniques (see Chapter 10).Ask a (female) patient to make a diary, noting the times when her fatigue is worst and recording her automatic thoughts at these times. Help her to refute irrational thoughts and record changes in her symptoms. Uncover underlying assumptions using the vertical arrow technique. These often include traits of perfectionism, low self-esteem, excessive guilt and an excessive reliance on achievement. 9. Moclobemide may be effective in some patients.
Hypochondriasis
Like the other somatoform disorders, hypochondriasis is treated more often by general practitioners than by psychiatrists. People with hypochondriasis are preoccupied with the belief that they have a serious physical illness. The belief is maintained despite adequate medical evaluation and explanation. Sufferers scan for information about the disorder, check frequently for symptoms and signs, and seek repeated medical reviews. High levels of anxiety are common. While the primary condition is relatively rare, symptoms of hypochondriasis often occur in the context of depressive, anxiety and other mental disorders. In contrast to those suffering unexplained physical symptoms, people with hypochondriasis, instead of being preoccupied with particular somatic symptoms, are worried instead about having a particular illness.
Whereas people with unexplained physical symptoms are preoccupied with their symptoms, people with hypochondriasis fear that they have a serious physical illness. Differential diagnosis
Hypochondriacal symptoms occur in a number of mental disorders. People with depression are often concerned that they have some serious illness. In severe cases, a person may suffer hypochondriacal delusions (e.g. that he or she has cancer or AIDS). Among the many concerns of someone with generalised anxiety disorder are often fears of having a serious illness. During a panic attack, a person may believe that he or she is going to die. Despite recognising the irrationality of their thoughts, people with obsessivecompulsive disorder may be plagued by fears of contracting a serious illness, and they may perform compulsive checking or cleaning
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rituals to avoid contamination. People with schizophrenia or delusional disorder may suffer bizarre hypochondriacal delusions.
People with depressive and anxiety disorders often suffer hypochondriacal symptoms. Formulation
Biological factors A history of prolonged or severe illness in childhood may be a predisposing factor. Recent severe physical illness may also trigger hypochondriacal fears. Psychosocial factors As mentioned above, hypochondriacal complaints often occur in the context of some other mental disorder, especially depression and anxiety. A parent or other family member with severe illness may provide a model for the person with hypochondriasis.The meaning of the symptoms for an individual may be an unconscious need for punishment, or a means of having dependency needs met. The behaviour tends, on the one hand, to elicit peoples concern, but on the other hand to frustrate and annoy them. The symptoms are reinforced by the secondary gains of avoiding ones normal responsibilities and gaining support and care from others. Reassurance seeking behaviour is reinforced by the reduction in anxiety that it causes in the short-term. However, over the long-term it leads to more disability and a need for repeated and more frequent reassurance. A sample formulation is shown in Box 19-4.
Hypochondriacal symptoms may express an unconscious need for punishment, a need to be cared for, or anger. Box 19-4: Formulation of hypochondriasis
A 35-year-old woman presents acutely anxious. She is preoccupied with the fear that she may have contracted AIDS after having an image of a bird tattooed on her shoulder two weeks before. She also has a secret that she cannot tell you. A preliminary test for HIV comes back negative, but she feels that she cannot cope having to wait another three months for a repeat test. Despite her anxiety, she can still enjoy herself when distracted from her preoccupations, and she has not experienced any panic attacks. She always idolised her father, a large man with tattoos who used to work in the merchant navy. However, she always felt rejected by him and resented the attention he paid to her brother with whom he would go fishing, play cricket, and talk sport. Three months later, after the second HIV test, she reveals the secretshe had been having an affair with a work colleague. Comment: Her anxiety is magnified by the guilt over her marital infidelity. The tattoo was an act of identification with her father. It may also have provided a more acceptable reason for presenting for the HIV test than her sexual behaviour.
Treatment
1. People with hypochondriacal concerns are often dissatisfied with the medical care that they have received in the past. Work to establish a therapeutic alliance by acknowledging the persons fears and symptoms. Take time to listen to the physical complaints. If the person can learn to trust you, he or she is less likely to consult other doctors, and will avoid having repeated investigations and procedures. 2. When presented with new symptoms, take a relevant history and perform a focused physical examination, but be careful to avoid investigations unless clearly indicated. Similarly, avoid specialist referral unless there are definite concerns about serious illness.
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3. Diagnose and treat any primary or co-morbid conditions: depression, anxiety, alcohol and substance abuse.
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Chapter 20
Sexual dysfunction
The prevalence of sexual problems in general practice populations has been estimated to be around 15 per cent. The commonest problems amongst women who seek help are hypoactive sexual desire disorder and female orgasmic disorder. Amongst men who present, erectile disorder and premature ejaculation are the most frequent1.
Ethical issues
Because of the intimate nature of sexual problems, those who provide sexual therapy must be clear about relevant ethical and boundary issues. 1. In addition to the rules about not divulging information outside therapy, the therapist needs to negotiate what information from individual therapy can be disclosed in couple therapy. For example, if a (man) discloses that he is having an affair, sexual therapy is contraindicated, and the therapist may find him/herself in the awkward position of having to inform the mans partner of this without stating the actual reason. Some therapists avoid this problem by reaching an agreement that anything discussed in individual therapy can also be raised in couple therapy. 2. It is essential to monitor your countertransference. Because of the intimate nature of sexual therapy, together with the powerful position of the doctor/therapist with respect to the patient, there are particular risks of boundary violations. A failure to acknowledge sexual attraction to a person may lead to unnecessary physical examination. Unless you acknowledge to yourself dislike of a patient, you may behave in a way that makes the person feel rejected or demeaned. Make sure that any intervention you initiate is for sake of the patient(s) and not for your own gratification. 3. Any sexual relationship between a therapist and a client within therapy can severely damage the client.The therapist faces deregistration and possible criminal charges.The ban on sexual relationships applies both during and after therapy. 4. There is no place for the direct observation of sexual behaviour in general practice settings. Similarly, there should be no need for physical contact or demonstration of anatomy or techniques. Written material andif acceptable to the clientsvideotapes can be used for this purpose. 5. Informed consent should be obtained before performing a genital examination of an individual of the opposite sex. The examination should be performed in the presence of a clinician chaperone who is the same sex as the patient. 6. Care must be taken not to impose your values on the patient. For example, while it may be reasonable to discuss a persons aversion to oral sex, there should be no compulsion upon him or her to perform it. If you feel uncomfortable with a couples values, refer them elsewhere.
7. The therapist should not discuss his or her own sexual behaviour.
8. Before delivering sexual therapy, the therapist should first undergo supervised training. Reading this text does not equip you to practise sexual therapy. However, you should be able to talk about sexual issues with patients, recognise common problems, provide sex education and advice on self-help texts, and make appropriate specialist referrals.
1
Hawton K. Sex Therapy: a Practical Guide. Oxford, Oxford University Press, 1985; 30-50.
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Any intervention must be for the benefit of the patient, not the therapist. It is essential to monitor countertransference.
The interview
To clarify the presenting sexual complaint, you need to assess the associated physiological (e.g. erectile difficulties), cognitive (e.g. negative thoughts, such as I am going to fail again) and emotional (e.g. feeling anxious and down) components before, during and after having sex. Identify the stage of the sexual response cycle at which problems occur and any relevant medical drug history and past psychiatric history. Try to answer the question, Why is this couple presenting with these problems at this time? There may have been sexual problems for some yearswhy are they presenting now? Clarify the time course and try to understand any precipitants and perpetuating factors. Ask the question, What was happening around that time? rather than, Why did the problems start? In addition to the general personal history covering early development, schooling, work, previous relationships, leisure and interests, and religious or specific cultural issues, take a sexual history that includes: family, religious and cultural attitudes to sex and sexual problems history of abuse or sexual assault age of first masturbation and the onset of menarche attitude to and feelings about the onset of puberty previous sexual relationships previous sexual dysfunction attitudes to aspects of sexuality such as nudity, masturbation, erotica and sexual fantasy sexual orientation
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attitude to pregnancy attitude to and fears about sexually transmitted diseases level of sexual knowledge and how it was obtained. Assess general aspects of the current relationshipits length and history, the level of mutual affection, shared interests, communication and relationships with children. Ask also about the sexual relationshipits history, mutual attractiveness, communication about sexual matters and infidelity. Assess each persons motivation for treatment. Perform a mental state examination, looking particularly for symptoms of depression or anxiety. Before performing a genital examination of an individual, you should first gain informed consent. It is wise to have a health professional who is the same sex as the client present as a chaperone. Look at the persons general appearance noting particularly any stigmata of an endocrine abnormality. Check blood pressure and peripheral pulses. Perform a genital examination noting any anatomical abnormalities. Perform a vaginal examination. Consider the following investigations: FSH, LH, prolactin and testosterone, fasting blood sugar, and urine screen. Other tests such as penile plethysmography and vascular studies are left to a specialist.
Biological factors
Neurological disorders Sexual functioning involves the interaction of a complex array of cortical, brainstem, parasympathetic (especially in arousal), sympathetic (especially in orgasm) and somatic neural pathways. The impact of a spinal lesion will depend on its level and whether it is partial or complete. Men with high spinal lesions may still have reflex erections. Frontal lobe stroke may lead to sexual inhibition. Temporal lobe damage is usually associated with reduced sexual desire. People with epilepsy, especially if there is involvement of the temporal lobes, may have reduced sexual desire. Vascular disorders Blockage of arteries supplying the genital area leads to erectile dysfunction. Hypertension is associated with erectile dysfunction and ejaculatory failure, problems that may be exacerbated by anti-hypertensive medication. People who have suffered a myocardial infarction may avoid sexual activity for fear of precipitating angina. Endocrine disorders Diabetes mellitus may lead to erectile difficulties due to peripheral neuropathy and vascular abnormalities that worsen with illness duration. These may be exacerbated by psychological reactions to early symptoms of the illness. Both Addisons and Cushings diseases are associated with reduced sexual desire. Klinefelters syndrome, cirrhosis, pituitary tumours, testicular tumours, undescended testes and mumps orchitis are associated with loss of sexual desire, erectile problems and ejaculatory failure. Hyperthyroidism is usually associated with reduced desire and erectile problems though hyper-sexuality has been reported. Hypothyroidism is associated with reduced sexual desire that may be partially reversible with treatment.
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Genital problems Vaginitis and venereal disease may cause local burning pain. Pelvic inflammatory disease, endometriosis and ovarian tumours are associated with deep dyspareunia. Curvature of the penis when erect in Peyronies disease may cause pain. Prostatism and venereal disease may present with pain on ejaculation. Other physical disorders Arthritis may lead to sexual problems because of pain. Sjogrens syndrome is associated with dyspareunia due to impaired vaginal lubrication. Serious systemic diseases cause debility and reduced sexual desire. Neoplasm may lead to sexual problems as direct or indirect effects of the illness itself or its treatment, or because of psychological reactions to having the illness. Drugs A number of prescribed and recreational drugs can impair sexual functioning (See Table 20-1). Unfortunately, many psychotropic drugs produce significant sexual side effects. Amongst the antidepressants, mirtazapine, moclobemide and nefazodone are generally least likely to cause problems. The effects of SSRIs are dose-related, but resolve in around a third of patients. Olanzapine or quetiapine are said to have few sexual side effects1. However, note that responses to specific drugs vary from one individual to another. While alcohol in low doses decreases anxiety, at high doses it impairs erectile function, retards ejaculation and reduces sexual desire. Cigarette smoking hastens atherosclerosis, which in turn causes sexual dysfunction. There are conflicting reports about the effects of marijuana. Some state that the drug enhances sexual experience; others that it can suppress testosterone levels. Heroin is associated with a loss of sexual interest as well as erectile and ejaculatory impairment.
Table 20-1: Some drugs that cause sexual problems (especially erectile dysfunction and retarded ejaculation)
Antidepressants
tricyclics SSRIs MAOIs
Antihypertensives
propranolol clonidine methyldopa hydrochlorothiazide spironolactone guanethidine
Mood stabilisers
lithium
Antipsychotics
thioridazine, chlorpromazine, haloperidol
Anticholinergics
benztropine
Hypnotics
benzodiazepines barbiturates
Others
digoxin indomethacin
Drugs of abuse
alcohol heroin methadone
Bazire S. Psychotropic Drug Directory 2001-2002: the Professionals Pocket Handbook and Aide Memoire. Bath, Bath Press, 2001.
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Sexual dysfunction
Psychosocial causes
Predisposing factors Peoples attitudes to sex are influenced by their upbringing and attitudes within their families of origin. Relationships with parents and siblings influence later close relationships. Young people who enter puberty earlier than their peers may feel ashamed and embarrassed. Those with late puberty may feel ashamed and inadequate. The response of the childs family is an important mediating factor. A persons sexual knowledge, skills and ability to communicate about sex all contribute to the quality of his or her sexual relations. A belief in certain sexual myths will affect a persons sexual behaviour. A persons values and attitudes will influence his or her willingness to use sexual fantasy and erotica, and may proscribe certain activitiesfor example, oral sex. Difficulties in sexual functioning are important consequences of childhood sexual abuse. The risk is increased if the abuse occurred at an older age, was frequent, and was associated with more negative experiences, such as threats, coercion or dislike of the other person. Penetrative sexual abuse is more traumatic than non-penetrative abuse. Precipitating factors Simple tiredness may be a significant contributing factor to sexual problems.The recommendation to practice sensate focus and other exercises may only exacerbate the problem. Any general stressor, such as the loss or death of a loved one, work difficulties or financial problems can have an impact on sexual functioning. Physical illness may have a psychological impact in addition to any direct physical impact.The discomfort that follows childbirth may persist and be complicated by depression or fatigue. An episode of sexual failure may lead to persistent problems as a consequence of performance anxiety. Couples undergoing invitro fertilisation treatment may develop sexual problems in response to the diagnosis of infertility. Sexual behaviour may be affected not only by the normal physiological changes of ageing, but exacerbated by negative attitudes to ageingfor example, myths about sexuality being the exclusive domain of the young and beautiful. After sexual assault, sexual problems are among the last symptoms of the trauma to resolve. Behaviours that summon memories of the assault are especially likely to persist. Perpetuating factors Most couples with sexual problems also report marital difficulties1. There may be difficulties communicating about sexual matters, in particular, about ones likes and dislikes. Episodes of infidelity can lead to feelings of guilt, anger, resentment and inadequacy. The response of a persons partner to an episode of sexual dysfunction will influence his or her response to it. A fear of intimacy or loss of attractiveness may play a part. Underlying assumptions about sexuality, including beliefs in sexual myths (see following page), influence sexual functioning. Some people find themselves more focused on observing themselves and thinking about how they are performing than in enjoying the experience. A couples sexual relationship will be affected by their access to a private, warm and comfortable place. Tiredness and overwork are common precipitating and perpetuating factors. Psychiatric disorders Reduced sexual desire is a feature of depression. In mania, there may be disinhibition and an increase in sexual behaviour that may later lead to shame and embarrassment. Schizophrenia is generally associated with a reduced sexual desire. Anorexia nervosa is often associated with a loss of interest in sexthe avoidance of mature female sexual functioning may contribute to the genesis of the illness.
Zimmer D. Does marital therapy enhance the effectiveness of treatment for sexual dysfunction? Journal of Sex and Marital Therapy 1987; 13, 193-20.
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Education
The aims of education are to provide new information, to dispel myths and misunderstandings, to reduce anxiety and to increase the couples confidence. Patients should be asked to buy one of the self-help texts mentioned on page 197. Negotiate the language you use and make sure that any technical terms are understood. It is probably best to begin by using medical terminology and then adapt your language to that used by the couple.
Educational interventions include providing new information, dispelling myths and providing reference material.
Have some pictures demonstrating male and female anatomy. It is useful to begin by comparing the general anatomy of the two and then to move on to the sexual anatomy. Discuss the normal variation in the shape and size of secondary sexual characteristics. Explain the role of the clitoris in orgasm. Note that the vagina is most sensitive at the entrance and that the inner two thirds are sensitive mainly to pressure. Have some diagrams that illustrate internal sexual anatomy. Explain the sexual response cycleexcitement, plateau, orgasm and resolution phases. Address any myths that the couple have about sexual functioning (see below). Reassure people about sex and ageing, in particular, that pleasurable sexual activity continues after menopause. Some common sexual myths Physical contact must always lead to sex. Good sex must always end in orgasm. Good sex equals intercourse. The man should always take the lead. Sex should always be spontaneous. A man should not express his feelings. A man should be ready for sex at any time. An erection should be there for the duration of sexual activity. A woman should not initiate sex. A woman should not enjoy sex too much, masturbate or use a vibrator. Men and women today are no longer influenced by old-fashioned sex-role stereotypes. Couples should have sex several times a week. Couples should always have orgasm simultaneously. A person should know intuitively what his or her partner wishes without being told. A woman should always be prepared to have sex if her partner wants it. A woman should be able to have an orgasm without direct stimulation of her clitoris. A woman should have an orgasm every time she has sex.
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References include: For the therapist Masters WH, Johnson VE. Human Sexual Response. New York, Bantum Books, 1966. Masters WH, Johnson VE. Human Sexual Inadequacy. New York, Bantum Books, 1980. Hawton K. Sex Therapy: a Practical Guide. New York, Oxford University Press, 1985. Spence SH. Psychosexual Therapy: a Cognitive-Behavioural Approach. London, Chapman and Hall, 1991. For the patient Heiman JR, LoPiccolo L, LoPiccolo J. Becoming Orgasmic: a Sexual Growth Programme for Women. Englewood Cliffs, Prentice-Hall, 1976. Delvin D. The Book of Love. London, New English Library, 1974. Williams W. Man, Woman and Sexual Desire: Self-Help for Men and Women with Deficient or Incompatible Sexual Drives or Interests. Sydney, Williams and Wilkins, 1986. Llewellyn-Jones D. Everywoman: A Gynaecological Guide for Life. London, Faber and Faber, 1982. Llewellyn-Jones D. Everyman. Oxford University Press, 1986.
The key sexual attitude is that lovemaking is not just about genital sexual relations, but rather, interacting physically and emotionally with someone you love. Structured problem solving
This is discussed in Chapter 6. Here is an example applied to the treatment of a sexual problem. Nigel and Polly have had difficulties in their sexual relationship since Nigels mother, Margaret, moved in six months ago.They formulate the problem as follows: We need to find more private time together. They generate the following possible solutions:
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Williams W. Man,Woman and Sexual Desire. Sydney: Williams and Wilkins, 1986, p130.
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Margaret to spend one night a week with Nigels brother, Martin Margaret to live with Martin Nigel and Polly to go out together once a week Margaret to move out to a retirement village They decide on the third option. The steps they need to take are for Nigel to check his afterhours roster to make sure he has every Thursday off; Polly to book a table at a restaurant; and Nigel to talk to Margaret about what she would like to do on Thursday nights. A month later, Margaret is spending every Thursday night with Martin and his family. Nigel and Polly usually pick her up on their way from their night out. Last week they went to the theatre, the first time for either of them in the past five years. They report improvements in both their general relationship and their sexual relationship.
Rational response
Mark suffers impotence. During sensate focus exercises, he thinks: Im a loser. (labelling) I have a problem, but I am working at it. The doctor says there are good success rates, and Bernice is keen to help. Our marriage is strong and our children are doing well. (refusing to accept praise) I may not be a model, but a number of others have commented on my good looks.
Bernice only says Im attractive because she feels sorry for me.
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Sensate focus exercises aim to remove anxiety about sexual performance through a focus on giving and receiving pleasure without necessarily proceeding to sexual intercourse.
Mismatched libidos
This does not appear in the DSM-IV, but may be one of the commonest presentations of sexual problems. Although each member of the couple has normal sexual desire, there is a mismatch between the two.1
Although each member of a couple may have a normal sexual desire, they may be mismatched.
Treatment Consider the differential diagnoses hypoactive sexual desire disorder, sexual aversion disorder, female sexual arousal disorder and male erectile disorder (see below) Use exercises to promote a positive sexual attitude, as discussed above. Develop an understanding of three possible situations and how to deal with them2: The couple both feel like having sex at the same time. Apart from the early stages of a relationship, this situation is uncommon. One partner is in the mood for sex, but the other, while not being actively averse to it, is not. This is probably the commonest situation.The person is encouraged to make love, but with no promise that it will lead to sexual intercourse. For example, he or she may relieve the partners sexual arousal through manual stimulation or the use of a vibrator. One partner feels actively averse to having sex. In this situation, it is essential that (he) is able to decline lovemaking. (He) might use a passive means of providing relief to his partnerfor example, by using a vibrator. Alternatively, (he) communicates, without apology, but also without anger, that (he) cannot make love now.
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Williams W. Man,Woman and Sexual Desire. Sydney: Williams and Wilkins, 1986. ibid.
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or only occur in specific situations, or be limited to one partner or one sexual activity. It is often associated with reduced arousal and difficulties with orgasm. Treatment Because of the many possible causes of this problem, it is essential to make a comprehensive formulation in order to individualise treatment. Use the general approaches to treatment mentioned above education, developing the key sexual attitude, marital therapy, structured problem solving, cognitive behavioural approaches and sensate focus. In some cases, it may be possible to increase the number of opportunities for heightened sexual desirefor example, by organising nights out together or, if acceptable to the couple, through the use of fantasy or erotica.
The principles of treatment of sexual aversion disorder are the same as for phobias. Female sexual arousal disorder
This is characterised by a failure of normal physiological changes in response to sexual arousal: pelvic vasocongestion, vaginal lubrication and swelling of the external genitalia. An essential text is Heiman, Lopiccolo and Lopiccolos book1. Treatment The specific techniques used in a particular case will depend on the individual formulation. Use non-specific approaches as above education, promoting the key sexual attitude, structured problem solving, cognitive behavioural therapy, marital therapy and sensate focus. The woman is encouraged to practise masturbation exercises. When she can arouse herself by this means, her partner becomes involved, initially observing her stimulate herself and later being guided by her to provide stimulation as part of genital sensate focus exercises.
Heiman JR, LoPiccolo L, LoPiccolo J. Becoming Orgasmic: a Sexual Growth Programme for Women. Englewood Cliffs, Prentice-Hall, 1976.
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If acceptable, a vibrator can be used. The couple then proceed to sexual intercourse. This should first involve only vaginal containment of the penis with the woman providing clitoral stimulation. For post-menopausal women, a vaginal cream may be prescribed to enhance lubrication. Oestrogen creams may be prescribed. Negative cognitions may include negative beliefs about a woman masturbating, especially in front of her partner; the man may feel a failure for being unable to satisfy his partner. The cognitive restructuring needs to be approached sensitively with care taken to take into account the value systems of the individuals involved.
Masturbation exercises are the cornerstone of the treatment of female sexual arousal disorder. Male erectile disorder
This involves a persistent or recurrent inability to attain or sustain an erection during sexual activity. In the DSM-IV, the condition is distinguished from sexual dysfunction due to a general medical condition. However, both physiological and psychological factors are often involved. Treatment Treat any underlying physical condition. Use non-specific techniques education, promotion of the key sexual attitude, structured problem solving and relationship counselling as above. The couple begin with sensate focus exercises, at first with the additional request that the man tries not to develop an erection, but rather focuses on the pleasure his partner provides. This reduces performance anxiety and self-observation, and encourages him to focus instead on receiving pleasure. The exercise is often best performed in the morning when the mans erection at its firmest. His partner may use gels or lubricants, or perform oral sex. The couple cease penile stimulation when the man has a firm erection, allow the erection to subside, and then repeat the process two or three times. This exercise helps reduce anxiety about losing an erection. In some cases, the anxiety is around maintaining an erection on vaginal penetration.The man should first practise ejaculating outside the vagina. Next, his partner progresses from rubbing his penis against her clitoris, to vaginal containment, and then to thrusting and completion of intercourse. Cognitive approaches may be used to address thoughts associated with performance anxiety. Physical treatments Sildenafil (Viagra) is an inhibitor of phosphodiesterase 5, the enzyme that breaks down cyclic guanosine monophosphate (cGMP).This in turn maintains arteriolar relaxation, mediated by nitric oxide, and so increases the duration and rigidity of erections in response to sexual stimulation.The dose is between 25mg and 100mg taken around one hour before sexual intercourse. Inhibitors of CYP3A4, including cimetidine, erythromycin and ketoconazole, slow its breakdown. It is contraindicated within 24 hours of taking nitrates (therapeutically for cardiovascular disease or recreationally as amyl nitrate). It should be used with care in men in whom sexual activity may precipitate adverse cardiovascular events, and in those with degenerative retinal disorders. Side effects include headache, flushing, dyspepsia, nasal congestion, diarrhoea and visual changes including a blue aura. Research into the use of sildenafil for women with sexual problems is under investigation.
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Other physical treatments include intracavernosal injection of alprostadil (Caverject), transurethral alprostadil administered via a micro-suppository, vacuum constriction devices, vascular surgery and penile implants. Note that men with low testosterone suffer low sexual desire and rarely present complaining of erectile dysfunction.
Contraindications to the use of sildenafil include the use of nitrates, severe cardiovascular disease and degenerative retinal disorders. Female orgasmic disorder
This involves a persistent or recurrent delay in or absence of orgasm. Treatment The woman is usually seen on her own at the beginning of treatment. A useful self-help guide is Heiman, LoPiccolo and LoPiccolos book1. Non-specific approaches include education and a discussion of her sexual attitudes. She is asked to examine and to become relaxed about her own body. She is then asked to note three positive and three negative things about her body. The next step is genital self-examination. She begins by identifying the different parts of her genital anatomy. She records her feelings and thoughts during self-examination, which then form material for cognitive restructuring. She then begins to explore herself with a finger. She should not be trying to produce an orgasm at this stage. Practice Kegel exercises. These involve recognising, gaining control of, and strengthening, the pubococcygeal musclesthose that interrupt micturition. She is then asked to identify sensitive spots, including the clitoris, and to proceed to masturbation. She may use erotica, fantasy or a vibrator. Once she is able to produce an orgasm through self-stimulation, her partner can be involved. She may begin by stimulating herself to orgasm in his presence and then by showing him what gives her pleasure. During sexual intercourse, she continues to stimulate her clitoris. The couple may then cease clitoral stimulation just before orgasm. However, a percentage of women will not experience orgasm by vaginal penetration alone, continuing to require some clitoral stimulation. Issues that may be relevant in cognitive restructuring include the belief that self-stimulation is not acceptable, that ones genitals are ugly, that a woman should be able to orgasm through vaginal stimulation alone, and fears of loss of control. The partners attitudes may also need to be addressed; for example the belief that he is inadequate if he cannot stimulate his partner to orgasm.
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couple then move to sexual intercourse with the man masturbating and then inserting his penis just before ejaculation. Negative cognitions that can impair orgasm include a fear of loss of control, a fear of pregnancy and negative responses to genitals. In cases where there are specific phobias, treatment proceeds as for sexual aversion disorder (see page 195).
Premature ejaculation
The main feature is ejaculation after minimal stimulation, or before or shortly after penetration. Premature ejaculation is often experienced by young men during their first attempts at intercourse, but is only a problem if it persists. Treatment The stop-start technique begins with the man attending to his level of arousal during masturbation, in particular, identifying the point of ejaculatory inevitability. He then practises ceasing self-stimulation just before this point is reached, allowing his arousal to subside before repeating the exercise. A similar progression it then practised with his partner. At first, the partner provides manual stimulation. Intercourse begins with brief containment and withdrawal. The times of penetration and the vigour of movements of penis in vagina then gradually increase. The squeeze technique is only indicated if the stop-start exercise is unsuccessful. The penis is grasped with the thumb on the fraenulum and index and middle finger across the coronal sulcus, and squeezed for around 510 seconds during high arousal. It is advisable to test the pressure required on the erect penis prior to practising the exercise.
Dyspareunia
This refers to pain experienced during intercourse. Treatment Treat any physical cause. Common causes include vaginal infection, venereal disease and inadequate lubrication. Causes of deep dyspareunia include endometriosis, pelvic inflammatory disease and ovarian tumour. Use non-specific techniques including education, relationship counselling (where applicable), relaxation and structured problem solving. When the pain is the result of impaired arousal, use the sensate focus exercises as discussed above. Give advice on positions that limit penetration, such as rear-entry and side-by-side. Practise Kegel exercises to enhance muscle control. Typical cognitive distortions include fears that ones genitals are abnormal, or of falling pregnant. The partner may fear harming her.
Vaginismus
The characteristic feature is the involuntary contraction of the muscles of the outer third of the vagina on vaginal penetration. It is commoner in young women and is associated with negative attitudes to sex and with past sexual abuse. Differential diagnosis Vaginismus may complicate any of the physical disorders that cause dyspareunia. Treatment Treat the underlying medical condition Non-specific approaches include education, relaxation training and relationship counselling
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where applicable. Construct a hierarchy of activities that successively approximate full penetration. Begin with self-observation and self-touching and move towards the insertion of one, two and then three fingers.The partner is then involved. Follow a similar progression during genital sensate focus.
The treatment of vaginismus includes progression through a hierarchy of activities that eventually lead to full penetration.
Referral
Unless you have undergone some supervised training in sexual therapy it is probably best to limit yourself to the provision of information and recommendation of self-help manuals. Indications for referral include the following: if you dislike or are sexually attracted to an individual if you are uncomfortable with the values or practices of the clients; for example, if you are uncomfortable treating a homosexual couple where the problems are long-standing, severe and have not responded to treatment where an individual has a history of serious sexual abuse if complications develop during treatment, such as serious marital discord in complex cases where multiple problems coexist if you do not feel confident in offering therapy.
The main presenting complaint of men with hypogonadism is low sexual desire. Homosexual patients
The problems that homosexual couples most often present with are the same as for heterosexuals and the principles of treatment are the same. If you are uncomfortable with homosexuality, you should refer them elsewhere. Because of ingrained negative attitudes to homosexuality, be careful to monitor your countertransference in dealing with homosexual clients. Some specific issues with regard to the treatment of male and female homosexual couples are discussed below.
If you are uncomfortable with homosexuality, refer homosexual couples presenting with sexual problems to a colleague with expertise in this area.
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Homosexual females The commonest reasons for presentation are low frequency of genital sexual activity and mismatched sexual desire. As with other couples, treatment may primarily involve education and reassurance1. Myths that can be addressed through cognitive restructuring include: Because I am a woman, I must know what my partner likes without asking her. Other lesbian couples have sex more often than we do. Women should not take the initiative in sexual encounters. The internalisation of societal homophobic attitudes may lead to low self-esteem and inhibited sexual activity and behaviour. It may be associated with the following negative beliefs: If I am not sexually active, I am not really homosexual. If I take a passive role, I am not really lesbian. Useful references include books by Loulan2 and Barbach3. Homosexual males The commonest problem that leads homosexual men to seek help is erectile dysfunction.While most sexual problems presented by homosexual men are similar to those of heterosexual men, some specific differences are discussed below. Gay sex includes mutual masturbation, oral and anal sex. Anal spasm is treated through the exclusion of physical causes (e.g. anal fissure), the provision of information, giving permission, and graduated insertion exercises similar to the treatment of vaginismus. Problems in sexual arousal may follow from demands for rapid response to sexual approaches in gay meeting places. On one hand, the individual may be opposed to this sort of activity in which sex is separated from intimacy or love. On the other hand, difficulties may develop in primary relationships because of fears of intimacy. A fear of contracting HIV infection may also play a part. Internalised homophobic attitudes can be addressed through cognitive restructuring. Many homosexual men continue to wrestle with their sexual identity. There are often particular pressures on homosexual relationships. Gay male relationships are more at risk than heterosexual marriages. Moreover, gay partners are said to be more likely to have relationships outside a primary relationship4. Concerns about how gay couples will be accepted by friends, family and other members of society may lead to anxiety about being discovered and a desire to maintain secrecy. Many homosexuals remain single. Others may marry, but continue to have homosexual fantasies and involve themselves in covert sexual activities.
Falco KL. Psychotherapy with lesbian clients: theory into practice. New York, Brunner Mazel: 1991. Loulan J. Lesbian Sex. San Francisco, Spinsters Park: 1984. 3 Barbach L. For Yourself. New York, Doubleday: 1975. 4 Reece R. Special issues in the etiologies and treatments of sexual problems amongst gay men. Journal of Homosexualtiy. 1988,15: 43-57. 5 Spence SH. Psychosexual Therapy: a Cognitive-Behavioural Approach. London, Chapman and Hall, 1991: pp 243-278. 6 DArdenne P. Sexual dysfunction in a transcultural setting: assessment, treatment and research. Sexual and Marital Therapy. 1986, 1: 23-24.
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Chapter 21
Trauma, memory and dissociation
The dissociative disorders are the subject of increasing attention in psychiatric research and clinical practice. Among psychiatric in-patients, their prevalence has been estimated to be around 5 per cent. A surprising finding of the National Survey of Mental Health and Wellbeing was that the commonest anxiety disorder in the adult population, with a 12-month prevalence of 3.3 per cent1 was post-traumatic stress disorder. Dissociative disorders are generally regarded as being among the post-traumatic syndromes: others include post-traumatic stress disorder (Chapter 15), borderline personality disorder (Chapter 23) and some of the somatoform disorders (Chapter 19). People who repeatedly self-harm have often been the victims of abuse (Chapter 3).Pure dissociative disorders are rare; more commonly, people present with a variety of dissociative, somatoform, anxiety and depressive symptoms, sometimes associated with selfharming behaviour and, in some cases, in the context of a personality disorder. The place of trauma in the aetiology of these disorders remains controversial. Indeed, there is a history of fluctuations between periods of acceptance and repudiation of the disorders themselves. Freud, in his early formulation of hysterical phenomena, attributed the symptoms to early trauma, especially childhood sexual abuse. However, he later rejected the seduction theory and postulated instead that the memories of his patients were the result of fantasy rather than of actual events. In legal settings, doctors are sometimes asked to give an opinion on whether traumatic memories are the result of past abuse, of conscious or unconscious fabrication, the result of suggestion from an over-zealous therapist, or some combination of these. The most recent demonstration of this controversy has been the debate over false memory syndrome. In a number of highly publicised cases, legal action was taken against alleged perpetrators of child sexual abuse, often family members of the complainant, on the basis of memories of abuse that were recovered during therapy. The legal process forced a polarisation of opinion on whether or not the abuse actually occurred. The devastating effects of these cases, irrespective of the legal outcome, further polarise the debate. Most writers presently agree on the centrality of traumatic experiences in the aetiology of these disorders. However, it should be remembered that reactions to stress and trauma vary considerably from one person to another. Some individuals develop dissociative disorders or other post-traumatic syndromes after exposure to relatively minor trauma, while others cope with severe and prolonged trauma without developing a post-traumatic syndrome. In this chapter, I first briefly review evidence of the profound effect of psychological trauma on memory. I then discuss the assessment and diagnosis of dissociative disorders and the principles of their treatment. Although general practitioners will not be expected to provide this treatment, they should nevertheless be able to make the diagnosis and to refer patients appropriately. They should be aware of the difficult transference and countertransference responses that can occur when dealing with these people, and they should consider these disorders in the differential diagnoses of other disorders, including psychotic disorders, with which they may be confused.
General practitioners need to be able to diagnose dissociative disorders, consider them in the differential diagnosis of psychotic disorders, and be aware of common countertransference responses to people who suffer from them.
Andrews G, Hall W, Teesson M, Henderson S. The Mental Health of Australians. Canberra: Mental Health Branch, Commonwealth Department of Health and Aged Care, 1999.
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Trauma has profound effects on memory. An inability to voluntarily recall traumatic events is coupled to an unconscious recall of these events in dreams, re-enactments and flashbacks.
On one hand, there is often an inability to consciously recall events.The amnesia may be for the specific event, but can also be for longer periods. In psychogenic fugue, the sufferer is unable to recall basic facts of his or her personal history and identity. On the other hand, the events are engraved in memory and find expression in dreams, re-enactments and flashbacks. Cues to the trauma may trigger these painful memories.
At the time of the traumatic event, dissociation is adaptive, because it isolates the person from an otherwise intolerable experience.
Dissociation is a psychological process through which traumatic memories, physical sensations, affects and ideas are stored and processed separately from, and are partially or completely inaccessible to, the rest of conscious experience. At the time of a traumatic experience, this process is adaptive, because it isolates the person from an event that might otherwise overwhelm him or her. He or she may even experience the event as if it is happening to another person. However, in the long term, a failure to integrate the experience within the persons life story may lead to serious disability and handicap (see Box 21-1).
Assessment
Consider the following four core dissociative symptoms: amnesia People with dissociative disorders may have gaps in memory or a sense of having lost time. They may lose track of conversations, or reach the destination of a journey and forget how they got there. As mentioned above, amnesia may be accompanied by flashbacks of traumatic events. Traumatic amnesia needs to be distinguished from simple forgetting, or failure to encode information due to impaired concentration. depersonalisation This is an unpleasant feeling of being detached from oneself. A man may feel as if he is standing beside himself observing his own actions. The observing self may be heard commenting on the participating self (pseudohallucination). People with dissociative disorders often have difficulty describing the experience.The process may be adaptive during
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exposure to a traumatic event, since it distances the person from involvement in the event and the associated pain, emotional distress and personal meaning. derealisation The person feels detached from the outside world, which seems unreal, unfamiliar and strange. Events may appear slowed down. Sounds may be muffled. Derealisation often accompanies depersonalisation. identity confusion/alteration The person lacks a coherent sense of who he or she is. A man may feel that he must act like someone else in social or work situations. There may be confusion over sexual identity. In cases of dissociative identity disorder, there may be separate personalities (alters) each with different names and distinctive attitudes and skills. The alters may be variably amnesic for the presence and actions of each other. Consider the diagnosis of a dissociative disorder in people who have had a large number of diagnoses in the past. Have a high index of suspicion when assessing people with a cluster of somatoform and mood symptoms such as headaches (including migraine), recurrent pelvic and abdominal pain, chronic fatigue, mood instability, self-harming, anxiety symptoms and eating disorders.
Consider the diagnosis of a dissociative disorder in people presenting with a cluster of the following symptoms: headaches (including migraine), recurrent abdominal pain, chronic fatigue, mood instability, anxiety and eating disorders.
The victims of trauma often suffer low self-esteem with strong feelings of guilt and shame over the traumatic events. Even those who suffered abuse as a child often feel that they were somehow to blame. At the time of the event, they were powerless to influence what happened, but being entirely dependent on the abusers, they may have had no choice but to believe that they were at fault.
Formulation
The likelihood of developing a post-traumatic syndrome increases with the intensity and duration of exposure to a trauma.Vulnerability to dissociative disorders and other posttraumatic syndromes also includes genetic and a number of other biological factors, including certain neuro-endocrine factors. Psychological factors that predispose to their development include certain personality traits (neuroticism and introversion), a history of mental illness, and past exposure to trauma. Social factors include a history of negative parenting, early separation from parents and low levels of education. A high level of social supports in the aftermath of a trauma is protective. The social relationships of abused people may continue to be influenced by past trauma.Through repetition compulsion, the person may continue to be revictimised, or through identification with the aggressor, the person may go on to abuse others (see Box 21-2).
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People abused as children may later be victimised by abusive partners. Diagnosis and differential diagnosis
The DSM-IV includes several dissociative disorders. Dissociative amnesia involves an inability to recall important personal information, usually of a traumatic or stressful nature, that is too extensive to be explained by ordinary forgetfulness. Dissociative fugue is characterised by unexpected travel away from home with an inability to recall ones past. Dissociative identity disorder, DID (previously called multiple personality disorder) is characterised by the presence of two or more distinct identities or personality states that recurrently take control of the individuals behaviour. Depersonalisation disorder involves a feeling of being detached from ones mental processes or body. However, it is rare for people to present with one of these syndromes alone. More commonly, people present with a combination of dissociative, somatoform, anxiety and depressive symptoms.
In general practice settings, dissociative symptoms most commonly occur in combination with somatoform, anxiety and depressive symptoms.
There is considerable overlap between the symptoms of dissociative disorders and other posttraumatic syndromes. Post-traumatic stress disorder often involves amnesia and re-enactment together with symptoms of increased arousal and avoidance of stimuli associated with the disorder. Borderline personality disorder may be associated with a history of child sexual abuse and is characterised by a dysregulation of emotional control. Dissociative symptoms may occur in the context of anxiety and depressive disorders or be co-morbid with these disorders. People with more complex dissociative conditions who have a history of childhood abuse also have high frequencies of non-organic pain, conversion symptoms and other physical complaints.
Other disorders that may arise as sequelae to traumatic experiences include post-traumatic stress disorder, borderline personality disorder, anxiety disorders, depression and the syndromes of unexplained physical symptoms.
Amnestic syndromes may be confused with organic mental disorders and substance abuse disorders. However, in these disorders there will be a defined physical cause and more global cognitive dysfunction. It is often more difficult to distinguish dissociation, especially in its more florid manifestations, from psychotic disorders. The full range of first rank symptoms of schizophrenia has been described in people with dissociative identity disorder. However, people with dissociative disorders rarely exhibit the negative symptoms of schizophrenia (amotivation, apathy, social withdrawal and anhedonia).
People with severe dissociative disorders can suffer a variety of symptoms typical of psychotic disorders.
Treatment
Therapy with people who suffer dissociative disorders is difficult and generally best left to a specialist in the area. Some will not be able to engage in any reconstructive therapy and are instead offered support, counselling and structured problem solving (see Chapters 6 and 8). It is desirable for these patients to form a therapeutic alliance with one general practitioner in order to avoid the iatrogenic complications of somatisation, including multiple investigations and procedures. Close liaison between the general practitioner and the therapist is essential.
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The general practitioner should try to establish a therapeutic alliance with the patient with a dissociative disorder, avoid unnecessary investigations of somatic complaints, and work in close liaison with the persons therapist.
Psychotherapy for dissociative disorders can be divided into three stages: providing safety and stability; recovering and processing the traumatic memories; and reintegrating the persons sense of identity and enhancing his or her ability to lead a fulfilling life and make enduring friendships. Helping the person process the traumatic event is best left to a specialist therapist. A person should never be forced to relive past trauma. This can be unbearable for him or her and may even constitute re-traumatisation.
The therapist should never force a person to relive past traumatic experiences. This can be unbearable and constitute re-traumatisation. Safety and stability
People presenting with dissociative disorders for the first time are often in crisis. The principles of crisis intervention described in Chapter 6 are applicable here. In the face of frightening nightmares and flashbacks, and the negative reactions of other people to her behaviour, a young woman with dissociative symptoms is at risk of self-harm or suicide.Try to establish a therapeutic alliance by listening to her complaints, empathising with her suffering and promoting trust and hope. Simple grounding techniques may be useful if she begins to dissociate during the interviewask her to let her hands feel the chair on which she is sitting, feel the floor through her shoes, open her eyes, look at you, and state her name and address.
Grounding techniques for a (woman) in crisis include asking her to let her hands feel the chair, feel the floor through her shoes, open her eyes, look at you, and state her name and address.
When dealing with someone with dissociative identity disorder it is important to recognise the different alters while, at the same time, reinforcing the fact that they exist within one person.You might address yourself to you all, or you might ask the alter in control to communicate with the other alters. Establish an agreement with all of the alters about therapy and the persons safety. Uncovering the cues to flashbacks will give clues to the meaning of the traumatic experience and will also give the person a greater sense of control over his or her symptoms.
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Medication
No drugs have been shown to be specifically effective in the treatment of dissociative disorders. However, co-morbid conditions often require the appropriate drug treatment.
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the person tells you and, on the other, avoiding suggestion about what might have happened. Be forthright with the person about your uncertainty and avoid being coerced into taking a stand one way or the other. Instead, focus on the persons current suffering and disability, and work towards lessening his or her distress and improving his or her level of functioning.
In dealing with memories uncovered in therapy, it is wise to adopt a neutral stance, avoiding on one hand, disbelief of what the person tells you, and on the other, avoiding suggestion about what might have happened.
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Chapter 22
Psychotic disorders
For people suffering their first psychotic episode, there is an average delay of one year between the development of symptoms and treatment of their condition. Seventy-five per cent of these people will have contacted their general practitioner during this period, but failed to gain access to care. Unfortunately, the longer the delay in treatment, the worse the persons prognosis, a consequence not only of a deterioration in psychosocial functioning, but also of neurobiological changes. Just as prolonged coma and lengthy periods of post-traumatic amnesia are associated with poorer clinical outcomes, prolonged psychosis also appears to be bad for the brain.
There is an average delay of one year between the development of psychotic symptoms and the commencement of treatment.
Background
Psychoses
The psychoses are conditions in which there is a loss of contact with reality.A person may develop false ideas about reality (delusions), experience false perceptions of reality (hallucinations) or suffer formal thought disorder (tangentiality, loose association, incoherence). Psychotic symptoms may occur as a consequence of a medical condition. In particular, the delirious patient may suffer any kind of psychotic symptom. Medical conditions are at the top of the diagnostic hierarchy and must be excluded before making the diagnosis of a functional psychosis. The principal functional psychoses are schizophrenia and bipolar mood disorder.
Medical conditions are at the top of the diagnostic hierarchy and must be excluded before diagnosing a functional psychosis.
The division of the functional psychoses into these two broad divisions reflects the influence of the German psychiatrist, Emil Kraepelin who, in the fifth edition of his textbook, published in 1896, made a distinction between two major syndromes, which he labelled dementia praecox (i.e. schizophrenia) and manic-depressive insanity (i.e. bipolar mood disorder). He made this distinction not only on the basis of characteristic symptoms and signs, but also on assumptions about their natural histories. Dementia praecox, as the term implies, was thought to be a chronic illness with a deteriorating course, while manic-depression was thought to be episodic with full recovery between exacerbations. This classification has been very influential and remains the basis of the DSM-IV and ICD 10 systems. However, it has recently come under challenge. People may present with features of both conditions. Rates of misdiagnosis of around 30 per cent have been reported. The same person may present with symptoms of schizophrenia on one occasion and bipolar mood disorder on another. Between 25 and 40 per cent of people presenting with schizophrenia recover and have no further psychotic episode, while some people with bipolar mood disorder suffer a chronic illness with severe disability and handicap and, in some cases, the development of negative symptoms. As a consequence, people presenting for the first time with psychotic symptoms are often diagnosed as suffering a psychotic illness rather than schizophrenia or bipolar disorder1.
McGorry P. A treatment-relevant classification of psychotic disorders. Australian and New Zealand Journal of Psychiatry 1995; 29:555-558.
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Functional psychotic disorders do not always fit neatly into the categories of schizophrenia and bipolar disorder. Epidemiology
The lifetime prevalence of schizophrenia is around one per cent.The first episode usually occurs in late teens, or early to mid-twenties. On average, females develop the illness a few years later than males. Bipolar disorder affects around 1.2 per cent of the population. The commonest age of onset is in the third decade, but it can occur at any age.
Aetiology
Schizophrenia appears to be caused by abnormalities in the development of the brain that become manifest in late adolescence or the early twenties, a time when the differentiation and maturation of the central nervous system is at its most complex. In many, but not all cases, the neurodevelopmental abnormalities are genetically determined. However, the pattern of inheritance does not conform to classical Mendelian genetics. Instead, multiple genes, each producing only a small effect on its own, combine to increase vulnerability. The risk of a person developing schizophrenia if one parent has the disorder is around 12 per cent (i.e. about ten times the risk in the general population). If both parents suffer from schizophrenia, the risk is around 40 per cent. Neurodevelopmental models of schizophrenia propose that genetic and non-genetic factors cause subtle alterations to the organisation of the brain in utero. Complications of pregnancy and childbirth may put the affected infant at increased risk of developing schizophrenia as an adult. Prenatal exposure to viruses has also been examined; however, the research is inconclusive. Genetic factors are also implicated in the cause of bipolar disorder. The risk of developing an affective disorder is around 30 per cent if one parent suffers an affective disorder (bipolar disorder, major depression or schizo-affective disorder) and 5075 per cent if both parents suffer an affective disorder. Mood disorders are associated with dysregulation in a number of biogenic amine systems, including norepinephrine, serotonin and dopamine. Abnormalities have also been observed in neuro-endocrine regulation, sleep architecture, circadian rhythms, and cerebral metabolism and blood flow. Doctors are often asked whether drugs such as marijuana or amphetamines cause schizophrenia. There is presently no conclusive evidence to support this proposition. However, marijuana and other psychoactive substances may precipitate an acute episode in someone with a predisposition to psychosis. Continued use will hasten relapse and worsen the prognosis.
Although the use of psychoactive drugs such as marijuana and amphetamines may precipitate acute episodes of psychosis and worsen prognosis, there is presently no conclusive evidence that these substances cause schizophrenia. Natural history and prognosis
There is a critical period of between two and five years after the first episode of schizophrenia when most of the impairment, disability and handicap arise. Therefore, active intervention is desirable during this stage of the illness. Recent studies suggest that the prognosis for schizophrenia is not as poor as previously thought. Between 25 per cent and 40 per cent of people who suffer a psychotic episode recover and never have another episode. Indicators of good prognosis include a rapid rate of onset, rapid recovery from the first episode, the presence of affective symptoms, stable pre-morbid personality, absence of blunted affect, presence of perplexity and confusion during the acute episode, later age of onset, early treatment, strong family support, and the absence of co-morbid problems such as substance abuse.
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Active intervention is desirable in the first two to five years after the onset of schizophrenia, the period when most of the impairment, disability and handicap arise.
Prior to the onset of psychotic symptoms proper, people with schizophrenia often suffer a number of prodromal symptoms. The prodrome lasts, on average, around two years. Although these symptoms are non-specific, bear in mind the possibility that they may herald the onset of schizophrenia. Have a high index of suspicion if there is a family history of psychosis or if there has been a recent marked deterioration in the persons level of functioning. See Table 22-1 for a discussion of prodromal symptoms and their treatment. The acute phase of the illness is characterised by the appearance of positive psychotic symptoms (delusions, hallucinations and formal thought disorder), accompanied by feelings of distress. There is often an identifiable precipitant to the first acute episode. A residual phase that includes many of the features of the prodrome may follow resolution of the acute phase (see Table 22-1). Negative symptoms are often a feature, including blunted or inappropriate affect (see Table 22-2). There may be high levels of disability and handicap. The natural history of manic episodes is typically of an abrupt onset and, if left untreated, a duration of around six months. Depressive episodes usually have a slower onset and a longer duration. For people with recurrent episodes, the periods of remission tend to get shorter, and the frequency and duration of depressive episodes tend to increase.
Positive symptoms include the following: 1. delusions false beliefs, foreign to the persons culture, which cannot be shaken by logical argument. The content may be persecutory, grandiose or pseudoscientific. The content of a paranoid delusion refers to the patient him or herself. It may be grandiose or persecutory. Delusions proper are non-understandable (e.g. the traffic light turned green and he knew that he was the Messiah), while secondary delusions are understandable (e.g. for some years he had been convinced that his wife was having an affair. His belief was again confirmed when he found cigarette butts in the garden and a footprint on the lawn). 2. passivity phenomena People with schizophrenia experience thought broadcast.They believe that their thoughts are accessible to others (for example, while visiting the local supermarket, a woman is mortified when she hears rude thoughts she has about her husband being broadcast throughout the building). They may experience thought insertion, believing that thoughts are put into their heads from outside; or thought withdrawal, that their own thoughts are taken away (for example, a woman believes that Hollywood stars are using her thoughts and feelings to portray characters in movies). 3. hallucinations People with schizophrenia may experience hallucinations in any of the sensory modalities (auditory, visual, kinaesthetic, olfactory, gustatory). However, auditory hallucinations are the most common. They may hear voices that repeat their thoughts or provide a running commentary on their actions.There may be two or more voices discussing the person. The presence of hallucinations in other sensory modalities raises the possibility of an organic cause. 4. formal thought disorder The individual jumps from topic to topic and does not take into account the needs of the listener. It can vary in degree from woolliness to incoherence. Other terms used to describe the disorder include tangentiality, looseness of association and knights move thinking. 5. catatonia This is defined as an increase in muscle tone at rest, which is abolished by voluntary movement. It includes mutism, stereotypy (maintaining a bizarre posture) and mannerism (odd, stilted ways of performing voluntary acts). Associated features include anhedonia, disrupted sleep patterns (e.g. sleeping during the day and staying up through the night), poor concentration, and impaired insight and judgement. Schizophrenia presents in a number of patterns. Disorganised schizophrenia is characterised by disorganised speech and behaviour, and flat or inappropriate affect. In paranoid schizophrenia, there are paranoid delusions and/or prominent hallucinations, but an absence of formal thought disorder and affective changes. A separate category exists for catatonic schizophrenia. People with undifferentiated schizophrenia have features that fit none of the above categories.
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Bipolar disorder
The diagnosis of bipolar disorder requires the occurrence of at least one manic episode, the characteristic feature of which is an abnormally elevated or irritable mood and labile affect for at least a week. Other features include a decreased need for sleep, inflated self-esteem, increased energy, pressure of speech, flight of ideas, distractibility, poor judgment (i.e. doing things at work or at school, or involvement in pleasurable activities, without regard for possible negative consequences). Flight of ideas is characterised by an increased flow of thought with a loss of goal. In contrast to the formal thought disorder of schizophrenia, the logical connections between thoughts are maintained in flight of ideas.The manic patient may suffer delusions that reflect the mood (e.g. grandiose or persecutory) or that are incongruent with the mood (e.g. delusions of reference). People with bipolar disorder are prone to suffering major depressive as well as manic episodes. As a consequence of their impaired judgement and disinhibited behaviour during manic episodes, people with bipolar disorder are at risk of suffering damage to their reputations, financial losses and legal problems.They tend to lose insight early in the course of the illness and so usually require hospitalisation, often against their will. Manic episodes range in severity from hypomania, in which the person does not suffer any marked disruption of social or occupational functioning, to mania with or without psychotic features. During some episodes, there may be a mixture of both manic and depressive features.
Psychotic depression
The features of major depression were discussed in Chapter 14. They include persistently depressed mood, anhedonia, neurovegetative function disturbance, psychomotor retardation or agitation, feelings of worthlessness and guilt, poor concentration, helplessness, hopelessness, recurrent thoughts of death and suicidality. In psychotic depression, delusions may be congruent with the mood (e.g. nihilistic, hypochondriacal, paranoid or delusions of poverty) or mood incongruent (e.g. religious delusions). Hallucinations, especially auditory, may also be a feature.
Delusional disorder
Delusional disorder is characterised by non-bizarre delusions occurring in the absence of other symptoms of schizophrenia. The delusions may be jealous (e.g. a man is convinced that his wife is being unfaithful), persecutory (e.g. an elderly woman believes that her neighbours are spying on her), erotomanic (e.g. a woman believes that the bishop in her church is in love with her) or somatic (e.g. a young man is convinced that he is infested with worms and keeps taking courses of medication). Delusional disorder is distinguished from schizophrenia by an absence of the following: prominent auditory or visual hallucinations, passivity experiences, formal thought disorder, catatonia or prominent negative symptoms. There may be kinaesthetic or olfactory hallucinations that are related to the delusional theme. The onset is often later than for schizophrenia, with most beginning in middle to later life. Deafness, social dislocation (e.g. immigration) and a sensitive pre-morbid personality are thought to predispose to the development of the disorder. See case example in Box 22-1.
Differential diagnosis
The differential diagnosis of the functional psychoses includes substance abuse and physical disorders (see Table 22-3). The delirious patient may suffer any of the psychotic symptoms mentioned abovenote the presence of an altered level of consciousness, disorientation, poor concentration and attention, and memory disturbance. People with dementia may suffer delusions, often persecutory, e.g. on themes that their belongings have been stolen. Epilepsy and cerebral lesions can produce psychotic symptoms. It is particularly important to consider a medical condition as the cause of psychosis in people over the age of 40 who present for the first time with psychotic symptoms. Some useful investigations are listed in Table 22-4.
Table 22-3: Physical disorders and substances that can cause psychotic symptoms
Common causes:
substance abuse intoxication with alcohol, amphetamine, hallucinogens, belladonna alkaloids, cannabis, cocaine, MDTA (ecstacy) or solvents; withdrawal from alcohol and sedatives delerium of any cause dementia epilepsy neoplasm, CVA, trauma especially involving frontal, temporal and limbic areas carbon monoxide poisoning Creutzfeld-Jacob disease heavy metal poisoning herpes encephalitis and other cerebral infections homocystinuria Huntingtons disease hyper- or hypothyroidism hyper- or hypoparathyroidism hypoglycaemia neurosyphilis migraine normal pressure hydrocephalus pellagra SLE Wernickes encephalopathy Korsakoff s psychosis Wilsons disease
Other causes:
The victims of childhood abuse may suffer a variety of psychotic symptoms in the context of a dissociative disorder (see Chapter 22). Schizoid, schizotypal and paranoid personality disorders can precede the onset of schizophrenia and share some symptoms (paranoid ideation, woolly speech, interpersonal withdrawal, odd beliefs and magical thinking).
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Treatment
Risk assessment
The first step is to ensure the safety of the patient and of others. Refer to Chapter 3 for a detailed discussion of the assessment of suicidality and dangerousness. People with command hallucinations (to self-harm or to harm others) and ideas of retaliation in response to persecutory delusions are at particular risk. Individuals may be unable to care for themselves or their dependents during acute psychotic episodes.
Medication
Schizophrenia Antipsychotic drugs are the mainstay in the treatment of acute schizophrenia and in relapse prevention. Over the past few years three new antipsychotics have become available: clozapine, risperidone and olanzapine (see Table 13-1). All have a lower propensity to cause acute extrapyramidal side effects than traditional antipsychotics and are associated with fewer negative symptoms. They may also be less likely to cause tardive dyskinesia. Clozapine is effective in cases that are resistant to treatment with traditional antipsychotics. However, it is only available through registered centres and requires close monitoring because of the risk of agranulocytosis. Parenteral preparations are useful in the treatment of people who fail to adhere to oral medication. Some practical prescribing points follow.
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McGrath J, Stedman T. How to treat schizophrenia. Australian Doctor 1994; October 28.
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The newer antipsychotics have fewer extra-pyramidal side effects than traditional antipsychotics and are associated with fewer negative symptoms. Clozapine has been shown to be effective in treatment-resistant schizophrenia.
When starting medications use low doses, gradually increasing to the standard prescribing range (start lowgo slow).The very young, older and first episode patients may only require small doses to control symptoms. Higher doses do not produce quicker or better outcomes, only more side effects. In general, doses above 15mg equivalent of haloperidol have no greater antipsychotic effect.
Doses above 15mg equivalent of haloperidol have no greater antipsychotic effect, only more side effects.
Agitation can settle within hours to days. However, the positive symptoms generally take between two and eight weeks to settle. Do not increase the dose every few days. Instead, be patient and wait for the drug to have its effect.
While agitation can settle within hours to days, the positive symptoms generally take between two and eight weeks to be alleviated.
If sedation is required for agitated or aggressive patients, consider the addition of diazepam. Anticholinergic agents are used to prevent acute dystonic reactions when commencing or changing the dose of antipsychotics, especially the high potency traditional drugs such as haloperidol. Once a steady dose is attained, the anticholinergic can usually be withdrawn.
Anticholinergics can usually be withdrawn once a steady dose of the antipsychotic has been attained.
In order to minimise the risk of developing tardive dyskinesia, maintenance medication needs to be continuous and at the lowest effective dose. Intermittent therapies, or drug holidays, are not recommended. For those who have had one acute psychotic episode, and who are symptom free on medication, guidelines suggest that a medication-free trial can be considered after one or two years of treatment. For those who have had two or more acute episodes, treatment should be continued for at least five years. Some people will require indefinite treatment. When changing antipsychotic medications, inform patients and their carers about the risks and benefits of the new medication and the importance of monitoring for early signs of relapse. A crossover phase is usually recommended. Reduce the dose of the first medication (or cease depot preparations) and gradually increase the dose of the second medication over several weeks. When changing from a traditional antipsychotic to risperidone, a crossover phase is required to avoid a cholinergic rebound syndrome. People on long-term therapy with traditional antipsychotics should be assessed at least once a year for tardive dyskinesia using the AIMS of similar screening instrument (see Appendix 10). It is important to remember that traditional antipsychotics may suppress the signs of tardive dyskinesia, while at the same time causing it. The signs may first become apparent when the dose is reduced. ECT is used in the treatment of catatonic schizophrenia, schizoaffective disorder, people with neuroleptic malignant syndrome, and in those who cannot take or are poorly responsive to antipsychotic medication.
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Mania Mood stabilisers (lithium, valproate and carbamazepine) and antipsychotics are used in the treatment of acute episodes of mania. Mood stabilisers are prescribed for relapse prevention (see Chapter 13 for a discussion of the use of these drugs). Contraindications to the use of lithium include pregnancy, renal failure and recent myocardial infarction. Common reasons for nonadherence to lithium include side effects (weight gain, poor concentration, tremor, stomach upset, urinary frequency), the burden of having to take medication over the long term, a feeling that ones creativity has been lost, and a wish to maintain the elevated mood of hypomania. The decision whether or not to embark on maintenance treatment depends on the number, severity and frequency of previous episodes; the ability of the person to recognise early signs of relapse; the presence of suicidality or dangerousness during acute episodes; and the strength of social supports. It is wise to involve the persons family and other carers in the decision. Following a first episode of mania, it is generally recommended that mood stabilisers be continued for a minimum of six months to prevent early relapse. It is essential to inform patients and their carers about the early signs of lithium toxicity and the circumstances under which it can occur (e.g. dehydration as a result of gastroenteritis or other cause). Women of childbearing age must be warned of the potential teratogenic effects of lithium. ECT is occasionally used in the treatment of severe mania and in people with a poor response to medication. Depression The treatment of depression is covered in detail in Chapter 14. The most effective treatment for psychotic depression is ECT, though a combination of antidepressants and antipsychotics is sometimes used. Lithium must be ceased during ECT administration.
Treatment adherence
Non-adherence to prescribed antipsychotic medication is common with a reported incidence of between 11 and 80 per cent.1 Some reasons for non-adherence are listed in Table 22-5.
The promotion of a strong therapeutic alliance will enhance adherence. Involve the patient in decision-making. Explain the reasons for your recommendations rather than trying to direct the patient to comply. Educate the patient and his or her family about the illness and the need for medication. In particular, explain possible side effects of the medication. Enlist others in helping a disorganised patient to monitor (his) medication. Dosette boxes may be useful for patients on a large number of medications. Listen to why the patient refuses to adhere and empathise with
Corrigan PW, Liberman RP, Engel JD. From noncompliance to collaboration in the treatment of schizophrenia. Hospital and Community Psychiatry 1990; 41:12031211.
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how (he) feels, but state clearly your own view and try to come to some compromise. Consider the use of depot medication.
Relapse prevention
Some common early signs of relapse in schizophrenia include sleep disturbance, social withdrawal, depression, anxiety, irritability, poor concentration, deterioration in work performance, worsening of positive symptoms (voices, delusions or formal thought disorder) and suspiciousness. It is important to ask the patient and his or her carers to reflect on the early symptoms of his or her last episode, and so clarify that individuals relapse signature. They need a clear plan of action should these symptoms recur.The treatment of early relapse involves increasing contact with the person and his or her carers, medication review, and dealing with the precipitants of the relapse, including substance abuse, non-adherence to medication, and life stressors. The onset of manic episodes is often abrupt, occurring over a period of hours to days. Common early signs include a decreased need for sleep, increased activity levels, elevated or irritable mood, and grandiose or otherwise unrealistic plans. Since people commonly lose insight early in the course of the illness, it is vital to involve the family and other social supports in recognising the individuals relapse signature and seeking early treatment. Common precipitants to manic episodes include stressful life events, substance abuse, the use of antidepressant drugs, the cessation of lithium, and disruption of the sleep-wake cycle. Women with bipolar disorder are at risk of developing postnatal depression or mania. Those who recommence mood stabilisers during the postnatal period are advised not to breast-feed.
Rehabilitation
Rehabilitation is the most time-consuming component of the treatment of prolonged illness.The aims of rehabilitation are to improve patients ability to survive independently in the community, to improve their social and family functioning, to maximise their educational and vocational potential, and to optimise their involvement in leisure and recreational pursuits. In assessing a persons rehabilitation needs, it is important to consider the individuals strengths, as well as his
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or her weaknesses. A rehabilitation plan will only be effective if the person is committed to its goals. Unless the goals are realistic, he or she will fail and may suffer a relapse, and you will feel frustrated. For one person a realistic goal may be a return to full-time employment; for another the appropriate goal may be maintenance of current functioning (see also goal setting in Chapter 9). It is useful to have an up-to-date list of the rehabilitation agencies in your area.
In assessing a persons rehabilitation needs consider both the individuals strengths and weaknesses.
People with psychotic illnesses may suffer deficits in social and living skillsself-care, shopping, using public transport, budgeting, cooking, housework, diet, physical health care, communication, problem solving and participation in leisure and social activities. These are addressed through skills training, the principles of which include breaking tasks down into small steps, keeping explanations clear and straightforward, repeating instructions and linking steps in a logical order. Skills training can be delivered on a one-to-one basis or in groups. Specific forms of skills training include goal setting (see Chapter 9), structured problem solving (see Chapter 6), communication and social skills training1. Various models of occupational rehabilitation have been developed. Job support networks provide vocational assessments, social skills training and on-site assistance in the workplace. Clubhouse projects provide both in-house tasks, such as clerical duties and kitchen work, as well as supported employment opportunities negotiated by the clubhouse and shared between clients. Self-help organisations include the Schizophrenia Fellowship. The Association of Relative and Friends of the Mentally Ill (ARAFMI) is a support group for carers. The coordination of a rehabilitation plan is time consuming for the general practitioner. However, several Medicare Schedule items introduced on the 1 November 1999 allow the general practitioner to bill for time spent in care planning and case-conferencing with other professionals involved in the persons care. Within public mental health services, case managers perform this coordinating role (see Chapter 1). A number of divisions of general practice across Australia are presently working with their local mental health services on programs of shared care. For example, the Logan Area Division of General Practice and the Logan-Beaudesert Mental Health Service have recently completed a shared care project that involved a casemanager working together with a group of six general practitioners in the care of 20 patients who suffer from schizophrenia. The project has now been extended to involve another 15 general practitioners and all of the case managers in the Service.
Within district mental health services, case managers coordinate patients rehabilitation plans. Family involvement
As a result of the shift in the delivery of mental health services from institutions to the community, much of the burden of care now falls on families and other carers. Having a family member diagnosed with a psychotic illness is stressful. Family members often fear that others in the family, especially children, will develop a similar illness. They will mourn the loss of hopes and plans for the person.They sometimes feel ashamed because of the stigma of the illness, and guilty that they may in some way have caused it. They may have to deal with difficult and demanding behaviours and, at times, they may even be afraid for their own or the patients safety. As a consequence, they may fear leaving the person at home alone, and be reluctant to have visitors
Treatment Protocol Project. Management of Mental Disorders 2nd Ed. World Health Organization Collaborating Centre for Mental Health and Substance Abuse, 1997.
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over to stay or to take holidays. Marriages are often put under great strain. Use counselling, structured problem solving and grief counselling to help families cope with these problems. Educate the family about the nature of the illness, the prognosis and treatment. Remind them that there is no evidence that patterns of family interaction or parental care cause schizophrenia, though family conflict, like any other stressor, can increase the likelihood of relapse. Involve the family in relapse prevention. Have a clear plan about whom they should contact in crisis, or when other problems arise. A good way of reconciling the persons right to privacy with the carers need for information is to see the patient and the family together. Carers groups such as the Association of Relatives and Friends of the Mentally Ill (ARAFMI) provide information and support to families of the mentally ill.
Use counselling and structured problem solving to help families deal with the stress of having a member with a psychotic illness. Complications
Depression and suicidality Schizophrenia is frequently complicated by depression. People with schizophrenia undergo a process of mourning, which may develop into major depression as they assess the impact of the illness on their life plans. The differential diagnosis includes negative symptoms of the illness, concurrent medical problems, substance abuse and extra-pyramidal side effects of medication. Antidepressants may be prescribed, but care must be taken as they can exacerbate psychotic symptoms. Suicide is the leading cause of premature death in people with schizophrenia with an estimated lifetime incidence of between 10 and 13 per cent. High-risk periods include the first six years after diagnosis and the period immediately following discharge from hospital. In addition to the general risk factors discussed in Chapter 3, specific risk factors in people with schizophrenia include young age, high IQ, high aspirations, high levels of pre-morbid achievement, chronic debilitating course of the illness, and an awareness of the losses sustained as a consequence of the illness. Patients may know others who have committed suicide. Between 10 and 15 per cent of people with major depression commit suicide. People with psychomotor retardation are at risk of suicide as their condition improves and they find the energy to act. During manic episodes people may, as a consequence of their impaired judgement, place themselves at risk. Violent behaviour People with schizophrenia are, as a group, at higher risk of committing violent acts than others in the community. However, the assessment of risk varies widely from one individual to another and requires the consideration of a large number of factors in addition to diagnosis (see Chapter 3). During a manic episode, sufferers may be prone to threatening or assaultive behaviour. People who are psychotically depressed are generally more of a risk to themselves than to others, but they may be aggressive towards those in their delusional systems. Family members can be at risk in murdersuicide. Anxiety Anxiety symptoms are not uncommon in psychosis. For example, a person with persecutory delusions may develop agoraphobia out of a fear of being attacked.After a psychotic episode, people may suffer a loss of confidence and fear recurrence of the illness. Address these complications through active rehabilitation, encouraging adherence to medication, and by taking other steps to prevent relapse. The management of specific anxiety disorders is discussed in Chapter 15. Substance abuse The prevalence of substance abuse in people with schizophrenia has been estimated to be as high
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as 40 per cent. Substance abuse worsens prognosis with longer and more frequent hospitalisations, and higher rates of homelessness, depression, suicide and violence.The management of substance abuse is described in Chapter 18. Some community mental health services offer groups for people with dual diagnosis of psychosis and substance abuse. Patients need to be educated about interactions with antipsychotic medications. People with bipolar disorder are prone to substance abuse during manic episodes, and they may self-medicate with alcohol or benzodiazepines. Physical and dental health problems The physical health of people with psychotic illnesses is often poor. A recent study found that ischaemic heart disease is the leading cause of excess mortality in psychiatric patients, accounting for 16 per cent of all excess deaths, compared with 8 per cent due to suicide1. There are high rates of smoking, obesity, underactivity, poor diet and poor dental health. General practitioners play an essential role in addressing these problems.
Complications of psychotic illnesses include depression, suicide, anxiety, substance abuse, and poor medical and dental health. Individual therapy
The cornerstone of the psychological treatment of people with chronic psychotic disorders is supportive psychotherapy (see Chapter 8). General practitioners are able to provide continuity of care to psychotic patients, something that is often lacking in public mental health services because of the frequent rotation of junior medical staff. Counselling and structured problem solving are used to deal with acute crises. A strong therapeutic alliance improves compliance and is one of the most important determinants of good outcome, but is often difficult to establish with people suffering psychotic disorders. Maintain a comfortable distancebe sensitive about intruding into areas that they do not want to discuss (though this may sometimes be necessary); negotiate the frequency and length of consultations with them; and respect their personal space. Educate patients about their illness and its treatment. Actively involve them in all aspects of their care. Clarify signs of relapse for each individual and, together with their carers, develop a clear plan of action should these appear. Be realistic about the outcome for those with chronic symptoms. Acknowledge the limits of what you can do. Allow the person to grieve the losses associated with having the illness. People with bipolar disorder are often ashamed and embarrassed by their behaviour during manic episodes. All people who suffer a psychotic episode face the stigma of having suffered a serious mental illness. For many patients, you will be the only person with whom they can discuss their psychotic symptoms. Accepting and trying to understand these experiences will often provide relief and strengthen the therapeutic alliance.
Accepting and trying to understand the experiences of people with psychotic illnesses will provide relief and strengthen the therapeutic alliance.
General practitioners commonly see people with psychotic illnesses for routine monitoring during the stable phase. Table 22-6 summarises important aspects of care in this phase.
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The goals are to prevent relapse; diagnose and treat complications; improve social, occupational and leisure functioning; deal effectively with stressful events; monitor for adverse effects of medication; and optimise family functioning. Length and frequency of appointments This depends on the persons current mental state. Patients will generally be seen around once a month for about 15 minutes, but more frequently (sometimes once a day) and for longer periods during exacerbations of the illness or in the face of stressful life events. Specific interventions Supportive psychotherapy The main elements are: holding and containment, genuineness, reassurance, positive reframing, explanation, suggestion and advice, encouragement, monitoring countertransference (see Chapter 8). Diagnosis and treatment of complications In particular, consider depression, suicidality, substance abuse and anxiety disorders. Monitor for signs of relapse Spend time with the patient and his or her family clarifying the relapse signature for that individual (e.g. broken sleep, withdrawal from family activities, eating alone, wearing bizarre make-up). Enlist the support of the family in spotting early signs. Treatment will depend on the assessment of the cause, but may involve an increase in medication, increased frequency of reviews, problem solving to deal with intercurrent stressors, treatment of intercurrent medical problems, counselling about adherence to medication and avoidance of substance abuse, or counselling to deal with family problems. Counselling and structured problem solving Use these techniques to deal with crises and other stressful life events (see Chapter 6). Education The family and the patient will want information about the illness, its prognosis and the treatment plan. Education is often an ongoing process, reinforcing and clarifying what has been said before, and dealing with new issues as they arise. Be sensitive to the patients need for some denial. Treatment planning and coordination This will be done in collaboration with other agencies involved in the persons care.The case manager at the local mental health service is the key figure in coordinating the persons treatment and rehabilitation needs.You can use the new Medicare items for remuneration of these activities. Review of medication Monitor side effects and efficacy. In particular, monitor every six to twelve months for any evidence of tardive dyskinesia. For those on lithium, monitor lithium levels, renal and thyroid function. Monitor adherence. Consider the indications for the use of atypical agents. Monitoring and enhancing adherence to treatment, including medication Educate the patient about the side effects of the medication and collaborate with him or her in finding the best balance between side effects and therapeutic effects. Warn the patient about the dangers of ceasing medicationwhile there may be temporary relief of side effects, there is an increased likelihood of relapse, which may in turn mean higher doses of medication later on. Rehabilitation The aim is to optimise the persons social, occupational and leisure functioning. Keep in touch with the persons case manager. Always ask the person what he or she has been doing since the last appointment has he or she been out, and how are things at home. Family involvement Ask to see the family regularly. Educate them about the illness and the treatment plan. Use counselling and structured problem solving to deal with acute stressors. Monitor the burden of care and the impact of the illness on individual family members and on the family system. Refer to appropriate support agencies. Monitor physical health Perform the same screening tests used for other patients.
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Chapter 23
Personality disorders
Personality disorders are persistent maladaptive patterns of behaviour and of perceiving and thinking about oneself and the environment, present since adolescence, that deviate markedly from a persons cultural expectations. They cause significant distress to that person and to others with whom she or he comes in contact. The DSM-IV describes ten disorders, which fall into three groups1: Cluster A includes paranoid, schizoid and schizotypal personality disorders. People with these disorders appear odd or eccentric. Cluster B includes borderline, narcissistic, antisocial and histrionic personality disorders. People with these disorders appear dramatic, emotional and erratic. Cluster C includes obsessivecompulsive, avoidant and dependent personality disorders. Individuals with these disorders often appear anxious, constricted and fearful. These diagnoses are purely descriptive and often an individual does not fit neatly into any one of them. Moreover, making a diagnosis does not eliminate the need to understand a person in terms of his or her history, current mental state and level of functioning. See Chapter 12 for a discussion of the psychodynamic assessment of personality. The behaviours that constitute the personality disorders are not in themselves maladaptive. Their value can only be judged by their impact on the individual and others in the contexts in which they occur. All people have dependency needsthey underlie our social behaviour and our attachments to others. Conscientiousness and perfectionism are frequently adaptive, especially when the consequences of careless behaviour are serious. Bold ambition and dreams of ideal love and beauty can be realised in works of art and other creative productions. A vigilant and suspicious mind may be valuable in uncovering corruption. Everybody lies, and nobody is perfect. Life would be dull if everyone obeyed the rules all of the time. As health professionals, it is not our primary role to make moral judgements about the people whom we treat.
The behaviours that constitute the personality disorders can only be judged as maladaptive in the contexts in which they occur.
These disorders are, by definition, long-standing ways of behaving and change only slowly. However, certain maladaptive traits may become attenuated over time, with or without treatmentfor example, the aggressiveness of the sociopath. Unfortunately, however, some people remain difficult into old age. General practitioners need to be aware of the common complications of the personality disorders, and to be able to diagnose and treat them. They include depression, anxiety and substance abuse. People with personality disorders are difficult to treat. Many of those whom TC ODowd dubbed heartsink patients fall into this category2. The general practitioner needs to understand common countertransference reactions to these people. By being conscious of these, you will be less likely to act out upon them. Your communication with them will be enhanced, as will your ability to treat their intercurrent mental and physical problems.You will
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. Washington DC, American Psychiatric Association 1994. 2 ODowd TC. Five years of heartsink patients in general practice. British Medical Journal 1988;297: 528-530.
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avoid some of the distressing personal reactions that can complicate their treatment. Moreover, your countertransference responses will provide valuable information about the person. The lives of people with personality disorders are often stressful and chaotic. In part, this is because rather than confront and deal with their problems, they tend to use denial, dissociation, acting out and other maladaptive defences to cope. Persuading these people to articulate and clarify their problems in often difficult. Nevertheless, the general practitioner should persist in helping the person to do so, and to use structured problem solving in dealing with them (see Chapter 6). Detailed discussion of past events, including past abuse, is generally best left to the persons therapist. Structured problem solving approaches may be supplemented by the behavioural and cognitive behavioural techniques described in Chapters 9 and 10. For people with severe personality disorders, supportive psychotherapy is used (see Chapter 8).
We are at greatest risk of acting out when patients arouse impulses and feelings in us that we habitually defend against.
In the following sections, I first describe the features of the disorders and some of their common psychiatric complications. I then describe the types of transference and countertransference reactions that commonly arise when dealing with these people, and how an understanding of these can inform treatment.
Cluster A
Paranoid personality disorder
Paranoid people have a pervasive suspiciousness and mistrust of others.They suspect the motives of others and are often preoccupied about whether or not friends and colleagues can be trusted. They may suspect the fidelity of their spouses. They are guarded and tend to read hidden and threatening meanings into everyday events. They bear grudges and are sensitive to anything that they perceive as a criticism. Paranoid people may go on to develop delusional disorder or schizophrenia.Their estrangement from others places them at increased risk of depression. Their fears of others can lead to agoraphobia. They may abuse alcohol or other substances in an attempt to settle their persistent anxiety and arousal. In the countertransference they evoke defensiveness. The interaction between you and the patient can sometimes be understood as the patient projecting their malevolent image of others onto you. First, recognise the angry feelings that you experience. Second, try to contain these feelings and not act defensively upon them. Acting out upon them may only confirm the patients paranoid perception of you. Be open and straightforward. If, for example, a man is suspicious about the notes you are taking, let him read them. If he criticises you for being late, apologise. Rather than dispute his perception of events, ask for more detail and empathise with how he must feel, given his paranoid beliefs. To do this, imagine how you would feel if you held similar beliefs. Do not press too hard for information from guarded patients, but rather empathise with the tension that they experience in having to be so vigilant. Do not be over-friendly, but rather maintain a professional distance. Encourage them to talk about their anger as an alternative to acting it out. Carefully monitor your countertransference. It is very easy to make a sarcastic remark or some other hurtful comment, which will only inflame the situation.
In dealing with a paranoid person, be open, straightforward and serious. Maintain a professional distance and do not press too hard for information.
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In some cases, it may be possible to begin to challenge a mans misconceptions by, for example, asking him about the presence of certain crucial evidence for his beliefs. If he says that his neighbour hates him, you might ask if the neighbour has actually said so. If not, you can calmly point out the uncertainty of his judgement.
With a schizoid person, tolerate the silences, do not be intrusive, and respect the persons silent self.
Cluster B
Borderline personality disorder
As a group, people with borderline personality disorder are amongst the most difficult to treat.The disorder is characterised by marked instability in interpersonal relationships alternating between the extremes of idealisation and devaluation. People with borderline personality disorder cannot tolerate being alone, and make frantic efforts to avoid abandonment. They may repeatedly selfharm. Their identity is disturbed. They are impulsive in their behaviour, and they exhibit rapid and intense fluctuations in affect between boredom, dysphoria, anger and anxiety. People with borderline personality disorder are at risk of depression, substance abuse and eating disorders. They may also be suffering the sequelae of abuse, including post-traumatic stress disorder, dissociative disorders or somatoform disorders. A well-validated treatment for people with borderline personality disorder is dialectical behaviour therapy, developed by Marsha Linehan1. This is based largely on behavioural and cognitive behavioural techniques, but also incorporates insights from a wide range of therapies, including psychodynamic psychotherapy. The therapy is usually delivered in two concurrent partsindividual psychotherapy and skills training. The skills training component has been manualised and is usually run in group sessions of two-and-a-half hours duration, once a week over 12 months2. This approach is presently being adopted at some sites in Australia. General practitioners should try to focus on the immediate here and now problems and stressors
Linehan MM. Cognitive-Behavioural Treatment of Borderline Personality Disorder. New York: The Guilford Press, 1993. 2 Linehan MM. Skills Training Manual for Treating Borderline Personality Disorder. New York: The Guilford Press, 1993.
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confronting the individual, rather than on the persons past problems, including any past abuse. Identifying and clarifying the precipitants to self-harming behaviour is often difficult because of the persons tendency to avoid problems through the use of denial, dissociation and acting out. The precipitant to self-harming may be an unpleasant affective state, for example, a feeling of emptiness and boredom when left alone. Use counselling and structured problem solving to help these people find more effective solutions to their problems. The techniques of cognitive behavioural therapy may also be useful.The techniques of supportive psychotherapy will be used for people with severe borderline personality disorder.
General practitioners should focus on helping people with borderline personality disorder identify, clarify and solve their current problems, rather than dwelling at length on their past abuse.
People with borderline personality disorder arouse intense countertransference feelings. In response to an idealised transference, you may be tempted to act out in a variety of ways. Feeling flattered at being told that you are the only person who has ever really understood and helped a person, you may try to live up to this image of the perfect therapist and have fantasies of rescuing him or her.You may regularly extend appointments beyond the agreed times.You may begin seeing a patient out of hours and in places outside your consulting rooms.You may find yourself accepting dinner engagements and even asking the person home. It is not unheard of for such patients to eventually move in with their therapists and enter into a sexual relationship with them. True to the countertransference, doctors who are drawn into these boundary violations typically act on the belief that the only way the persons problems could be alleviated was through an intimate relationship with them. A corollary of the persons idealisation of you may be his or her devaluation of others involved in their care. Failing to acknowledge and recognise feeling so special, you may find yourself criticising your colleagues, accusing them of being unable to understand the person and of not caring enough about him or her. For devalued therapists who are struggling to cope with a hostile, self-harming patient, there is nothing harder to tolerate than the self-righteous, idealised therapist who is critical of their best attempts at treatment.
People with borderline personality disorder may at different times idealise or devalue their therapists.
This conflict can be understood through the concept of splitting, a defence mechanism that has both intrapsychic and external manifestations. The intrapsychic component involves people having polarised views of themselves and others, either all good or all bad. Instead of recognising that people are a combination of both good and bad, such people keep good and bad representations of themselves and of others separate and compartmentalised. In some cases, they have been the victims of abuse and, by keeping good and bad object representations apart, they protect the good from being destroyed by the bad. The external manifestations of splitting are seen when conflict arises between other people in their milieuin particular, between idealised and devalued therapists. When splitting between therapists does occur, try to recognise it. Meet with your colleague and listen to his or her experience of the patient. Try to reach agreement on how the person should be treated. If possible, meet together with the patient, united in your approach. If you treat these people, you will experience what it is like to be treated as both good and bad. At one time you will be idealised, at another, devalued.
Idealisation and devaluation can be understood as external manifestations of splitting. Intrapsychic splitting involves keeping good and bad representations of the self and of others separate and compartmentalised.
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It is particularly difficult to deal with the borderline patients self-destructive behaviour, which may include cutting, over-dosing, burning with cigarettes, risk-taking and sexual promiscuity. While the intention behind these behaviours may not be to commit suicide, people with borderline personality disorder have a suicide rate of around 8 per cent. The risk of suicide in people who self-harm has been estimated to be 140 times the population average. The self-harming behaviour may be a maladaptive way of seeking help, a behaviour learnt within past abusive relationships. It can also be understood as a type of acting out through which an unbearable affect (emptiness, boredom, anxiety, helplessness) can be neutralised. Self-harming behaviours promote strong countertransference responses. Anger is prominent indeed, the affect may at times be more accurately described as hate. Be careful to acknowledge such feelings to prevent acting out. You might withdraw or make a sarcastic remark. Instead of acting out the hate directly, you might, through reaction formation, do the opposite and make desperate attempts to rescue the person. Rescue fantasies may arise from anxiety and guilt about the persons behaviour, and a feeling that you are helpless to do anything about it. There is the danger that the extraordinary measures you take to stop him or her from self-harming may ultimately do more harm than good.They will reinforce the persons feelings of helplessness and could even lead to boundary violations. Instead of embarking on desperate attempts at rescue, set clear limits about what you can and cannot realistically do. Be open and discuss these limits with the person. For example, acknowledge that ultimately the safety of a young woman is in her own hands. Seek an agreement with her to seek other more adaptive ways of dealing with her feelings by, for example, speaking to someone about how she feels. At the same time, acknowledge her need for such behaviour; recognise that it is a solution to a painful and distressing state of being. Use structured problem solving to find more adaptive ways of dealing with stressors.
In response to self-harming behaviour express your concern, but acknowledge the limits of what you can do. Try to reach a safety agreement with the person. Focus on the here and now issues and use structured problem solving to deal with him or her.
People with borderline personality disorder, unable to articulate why they have harmed themselves, may sometimes present a bland, smiling affect in response to self-harming behaviour. This response can be understood as a form of splitting in which the impulse to self-harm has become separated from the idea and the affect with which it was associated. As children, this was often the only way these people had of dealing with sexual abuse or other traumatic experiences over which they had no control. Do not join in, laughing and clowning. If you do so, you are, like the patient, probably defending against acknowledging your own fear and despair. In general, it is advisable to maintain a serious demeanour. Do not be annoyed by the bland affectacknowledge the attempt to put a brave face on a frightening and distressing experience.Try to understand and articulate the affect that the person defends against. Ask about precipitants in order to help the person to connect the affect with the idea and the impulse. For example, it might be useful for a young man to write down what is running through his mind at times when he feels the need to harm himself.
In response to a bland, smiling affect, do not clown and joke or get annoyed with the person. Remain serious and concerned.
Do not force people to describe their experiences of abuse. This may constitute a form of abuse in itself. Instead, allow them to confront these memories when they choose. This will be difficult and unpleasant. Monitor your countertransference responses. Acknowledge to yourself any voyeuristic gratification that you experience to ensure you do not act out upon it by, for
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example, probing the person for more detailed descriptions of the abuse. A paradox exhibited by people with borderline personality disorder is that while being in a state of emotional turmoil, they may nevertheless be unable to adequately grieve their losses. Assist them through the mourning process (see Chapter 7).
People with narcissistic personality disorder are prone to depression and substance abuse when they fail to live up to their high expectations of themselves.
Grandiosity, an insatiable need for admiration and a lack of empathy with others characterise the disorder. Narcissistic people are preoccupied with fantasies of unlimited success, power, brilliance and ideal love. They are vulnerable to feeling ashamed when they fail to live up to the exacting standards that they set themselves. They have a sense of entitlement about receiving favourable treatment and expect obedience to their every wish. When not envious of others, they are convinced that others must be envious of them. Their manner is arrogant, haughty, superior and dismissive. In the transference they may, like those with borderline personality traits, idealise the therapist. Therapists who are unaware of their own narcissistic needs may accept this projection and act out upon it, for example, by encouraging the persons devaluation of his or her previous therapists. Boredom is a frequent countertransference response to people with narcissistic personality disorder who talk continuously about themselves while being quite oblivious of the therapist. Failure to recognise and contain these feelings may lead to withdrawal from the person, or angry retaliation at his or her selfishness. In dealing with narcissistic people, you may feel controlled as they vigilantly observe and criticise anything that may be construed as a lack of complete attention to themselves. At such times it may be useful to interpret their response by saying, for example, You seemed upset when I reached for the medical record. You will also have to cope with the persons devaluation. If you fail to acknowledge and contain your feelings of hurt, you may be tempted to retaliate against him or her.This may be particularly difficult to avoid if you fail to acknowledge your own narcissistic needs.
The antisocial person will try to corrupt you. For example, a patient of a psychiatrist who was having difficulty selling his house, offered to burn it down so that the psychiatrist could collect the insurance. Be careful not to laugh or otherwise show any appreciation of such a suggestion. Such people mean what they say and clear rejection and disapproval should meet such comments. Confront the persons denial and minimisation of his antisocial behaviour. For example, if he says, I sorted him out, ask exactly what he did and then clarify the action: You mean you hit him.
With the antisocial person, confront the denial of his antisocial behaviourdo not collude with the excitement he experiences hurting othersand try to connect actions with internal affects and thoughts. Do not have high expectations of success.
Be careful not to empathise with the patients sense of excitement and domination when he describes hurting someone else. Such a response is a type of pseudo-empathy and represents collusion with the persons antisocial behaviour. Like people with borderline personality disorder, antisocial people act out strong impulses as a defence against acknowledging their affective and ideational originsfor example, their feelings of emptiness and anxiety in response to not having what they want.Try to connect actions with internal feeling states and carefully examine precipitants to impulsive behaviour. Finally, accept the fact that these people are very difficult to change. Be resigned to the fact that they probably will succeed in deceiving you at some point. In some cases, they are probably untreatable. Do not have high expectations for success; otherwise, you are likely to be disappointed.
The impressionistic style of communication of people with histrionic traits is a manifestation of their primary defencesrepression and denial.
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As a further defence against threatening thoughts and feelings, histrionic people may try to switch the focus of attention onto you and begin to question you about your life. Falling into this countertransference trap, you may then find the suggestible histrionic patient taking on your own attitudes and beliefs. It is generally unwise to self-disclose to histrionic patients. The person with histrionic personality disorder may develop an erotic transference towards you. A failure to monitor your own countertransference responses could lead to boundary violations. On the other hand, an understanding of the origins and meaning of the erotic transference can provide important insights into the patients neurosis.
Cluster C
Obsessivecompulsive personality disorder
This set of personality traits is different from obsessivecompulsive disorder, which is characterised by obsessions (recurrent, unwanted thoughts) and compulsions (ritualised acts that are performed to decrease anxiety). See Chapter 15 for a discussion of obsessivecompulsive disorder. People with obsessivecompulsive personality disorder are preoccupied with orderliness and doing things perfectly. They have a need to be in control. They tend to be rigid and lacking in spontaneity. They have difficulty seeing the wood for the trees. While some of these traits are adaptive in our societyfor example, in obtaining an academic degree or in being a medical practitionerpeople with this personality disorder are at risk of depression when they fail to meet their own exacting standards, and they become anxious and irritable when their sense of being in control is threatened.
People with obsessivecompulsive traits have a need to be in control and are prone to anxiety and irritability when this is threatened.
Typical countertransference reactions include boredom and irritation with the patients circumstantial and over-inclusive speech. In response to their controlled affect, you may feel distant and cold towards them.You may overlook some of their problems because of the discomfort you have in confronting your own obsessivecompulsive traits. In response to the tendency of these people to dominate the interview, you may be drawn into a battle for control. As with the other personality disorders, the first step in dealing with these people is to be aware of your own countertransference responses. Try to get beyond their words to uncover the feelings and impulses behind them. In particular, allow them to acknowledge their anger. In patients with obsessivecompulsive personality disorder, anger may be disguised by their use of the defence of reaction formation. For example, a mans repeated expressions of concern about anothers well being may disguise his anger with that person.
People with avoidant traits are prone to depression, anxiety and substance abuse.
In the countertransference, you may feel bored because of the persons silences and his or her generally inhibited behaviour.Avoidant patients expect people to be critical of them, to humiliate
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them and to put them to shame. Acknowledge any such impulses so as to avoid acting out upon them. Encourage the person to confront feared social situations. Tolerate their silences.
Dependent people often fear that if they get better, they will lose your support.
All of us have conflicts over dependency. A motivation for entering a caring profession may be to provide the care that an ideal caregiver might have given to us. Because of our own dependency issues, we may tend to deny aspects of the countertransference when dealing with dependent people. Be careful to monitor feelings of disdain or contempt for the persons clinging behaviour. On the other hand, the impulse to try to provide perfect care may only lead to exhaustion and disappointment.
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Chapter 24
Child and adolescent mental health
Child and adolescent mental health problems need to be understood in the context of: a) the childs stage of development b) the childs social contextfamily, school, peers and work.
Developmental considerations
Failures to achieve normal developmental milestones (e.g. sphincter control, speech) or regression to an earlier developmental stage (e.g. enuresis, encopresis) are important diagnostic signs. The developmental stage will determine the way in which problems are expressed.The developmental stage also determines the appropriate interview and therapy techniques.
Childhood mental health problems often present with signs of regression to an earlier developmental stage.
Adolescence is sometimes viewed as a period of normal crisis, but, in fact, most adolescents maintain good relationships with their parents through this phase.Adolescence involves significant maturational changesthe physiological changes of puberty; cognitive changes (in particular, the development of abstract thinking and a more sophisticated moral sense); psychological changes (in particular, the consolidation of the adolescents identity); and increased social expectations towards increasing self-reliance and autonomy, preparation for a career, detachment from parents, and the development of intimate relationships.
Social context
Children are dependent on adultstheir parents, teachers, and others, including their general practitioner. It is often parents or teachers who first recognise that a child has a problem. A childs problems are influenced by and, in some cases, are reflections of family problems or problems at school. Treatments, especially in younger children, almost always involve the childs parents, family, and other authority figures such as teachers.
The treatment of childhood mental health problems requires the involvement of parents, family members and other authority figures such as teachers.
The social world of adolescents includes the family, school, peers and work colleagues. The developmental changes may challenge both the family and the adolescent. For example, the parent who is dependent on a child will feel threatened when that child begins to develop more autonomy during adolescence.The adolescents progress at school and the quality of his or her peer relationships are important measures of his or her adaptation. Problems in these areas constitute important aspects of the adolescents disability and handicap.
Epidemiology
Children
Around seven per cent of children suffer moderate to severe mental health problems with a further 15 per cent having mild problems. The prevalence of conduct disorder is about four per cent, while that of emotional disorder is about 2.5 per cent. The prevalence of mental disorders overall is about twice as high among boys as it is amongst girls, though the prevalence of
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emotional disorders may be slightly higher in girls. Risk factors include low IQ, brain disorder (34 per cent prevalence of concurrent mental disorder), physical illness (10 per cent prevalence of mental disorders), discordant family relationships, mental disorder in either parent and lack of emotional warmth displayed towards the child by the parents.
Adolescents
The prevalence of moderate to severe mental disorders among adolescents is between 1520 per cent, about twice that found in childhood. The prevalence in boys peaks in early teens, while in girls it peaks in late teens. About half of the mental disorders are conduct disorders. Most of the rest are emotional/neurotic disorders. Psychotic disorders may present in this age group.
The prevalence of mental disorders among adolescents is about twice that in children.
Mental disorders presenting in adolescence include both those typical of childhood (for example, enuresis, school refusal), as well as those typical of adult populations (major depression, panic disorder, schizophrenia and agoraphobia).
In assessing a childs mental health problems, interview the family, the child alone and the parents.
Although the psychiatric interview follows a similar format to that of the adult interview, there are some differences. In assessing the presenting complaint, it is important to note the context in which the problems occur. Specifically, problems may exist at home, at school or in both contexts. A specific learning difficulty, for example, may lead to problems at school but not at home. A child with disturbed parents may show no evidence of problems while at school. In assessing the level of a childs disability and handicap, ask about relevant developmental tasks (i.e. school performance, relationships with peers, teachers and the family, evidence of any antisocial behaviour, and involvement in extra-curricular activities).Take a developmental history of the child (i.e. obstetric history, early milestones, school adjustment and social development). Note important adverse events, for example serious medical procedures, hospital admissions, separations from parents, family bereavements, or frequent changes of address or school. Assess the personalities of the parentstheir ages, occupations, work histories, relationships with their parents, and their current marital and sexual adjustment. The assessment of a childs mental state is best conducted in an age-appropriate setting. For young children, this is often best done by observing the child at play. The content of a childs inner world may be most eloquently expressed through his or her drawings. Useful projective tests include asking the child to draw pictures of a person and of the family, and asking what he or she would like if given three wishes. Assess the young persons developmental level and
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language ability. Note his or her ability to separate from parents and his or her attitude to you. Transference and countertransference reactions may be stronger and less defended than those experienced between two adults.
Specific conditions
The following sections deal with the diagnosis and treatment of some of the common child and youth mental disorders. I also discuss the assessment and management of child abuse, and advice to parents on managing a childs behaviour. See Chapter 18 for a discussion of alcohol and substance abuse, and Chapter 22 for the treatment of psychoses.
Tic disorders
Tic disorders range in severity from transient tic disorder, through chronic motor or vocal tic disorder, to Tourettes disorder. Tics are rapid, repetitive, non-rhythmic movements of sudden onset. They may involve stereotyped movements or vocalisations. Although experienced as irresistible, they can be delayed. There are often premonitory sensations localised in the region of the tic.The location, duration, intensity, complexity and frequency of tics may vary over time. They tend to be exacerbated by stress, and attenuate during absorbing activities and sleep. Simple motor tics include blinking, shrugging, grimacing and coughing. Complex motor tics include grooming, holding odd facial expressions, squinting, tapping, hopping, stomping or making rude gestures. Common simple vocal tics include throat clearing, grunting, sniffing, snorting or saying aaah. Complex vocal tics include repeating words of phrases out of context such as, You bet; repeating ones own words or phrases; repeating others words, phrases or sentences; and swearing or using obscene language (coprolalia). Assessment and diagnosis The disorders described in DSM-IV are distinguished from one another by their duration, severity and the variety of tics present. Transient tic disorder is characterised by tics occurring on most days for at least four weeks, but for no longer than a year. Chronic motor or vocal tic disorder requires the presence of either motor or vocal tics, but not both, that occur regularly for at least a year. For a diagnosis of Tourettes disorder to be made, there must be both motor and vocal tics for at least a year. All require an onset before the age of 18 years.
The diagnosis of Tourettes disorder requires the presence of both motor and vocal tics for at least a year with an onset before the age of 18 years.
In addition to the diagnostic assessment of the tic disorder, one should also note the presence of any co-morbid conditions, in particular, obsessivecompulsive disorder, attention deficit hyperactivity disorder, depression and anxiety disorders. Assess the levels of symptoms in different settings, the levels of disability and handicap, the impact of the illness on family functioning and the presence of stressors that may be exacerbating the tics. Differential diagnosis Descriptions of tics and other abnormal movements are given in Table 24-1.Abnormal movements occur in a variety of physical illnesses (e.g. Huntingtons disease, post-viral encephalitis, multiple sclerosis, cerebrovascular accident, and head injury) or in association with substance use (e.g. neuroleptics and stimulants). Tics must be differentiated from Parkinsonian side effects of neuroleptic medications (including tardive dyskinesia).
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Epidemiology Transient tics occur commonly, with an estimated lifetime prevalence as high as 20 per cent. Tourettes disorder is rare, with a prevalence of around one per 2000. The disorders are more common in boys than girls1. Familial pattern A vulnerability to Tourettes disorder is transmitted by autosomal dominant pattern of inheritance with a higher penetrance in males (99 per cent) than in females (70 per cent)2.The vulnerability may be expressed in tic disorders of differing severity. There is an increased incidence of obsessivecompulsive disorder in people with Tourettes disorder.
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risk-taking, or overly dependent behaviour. Normal developmental steps may be delayed. These negative reactions can be dealt with in therapy using the counselling and structured problem solving techniques described in Chapter 6. Family therapy Issues addressed in family therapy include the stress of the illness on other family members, the exacerbation of pre-existing marital conflict, and the role of family stress and conflict in exacerbating symptoms (see Chapter 5). Treat co-morbid conditions These include obsessivecompulsive disorder, attention deficit hyperactivity disorder, depression, anxiety disorders and learning difficulties. Pharmacological treatment Clonidine, an alpha2-noradrenergic agonist, is used in doses up to 3 to 4 micrograms/kg/day orally to suppress tics. Doses begin at 50 micrograms a day, increasing by 50 micrograms a week. Doses should not exceed 300 micrograms per day1. A trial of at least three months is required to assess its full therapeutic effect. Side effects include sedation, dry mouth, headaches, postural hypotension and rebound hypertension on abrupt withdrawal. Haloperidol, in doses up to 0.075 mg/kg/day orally has been used in the suppression of symptoms in Tourettes disorder.The dose should begin with 0.250.5mg orally and be gradually increased every one to two weeks1. It has a more rapid onset of action than clonidine, but also more disabling side effects, including extra-pyramidal symptoms, sedation, weight gain and endocrine abnormalities. Particular care must be taken to screen for the development of tardive dyskinesia (see Appendix 10). Serotonin reuptake inhibitors are used to treat co-morbid obsessivecompulsive symptoms. The treatment of impulsivity, inattention and hyperactivity is more difficult as stimulants may worsen the tics. We recommend referral to a child psychiatrist if clonidine and haloperidol are ineffective or poorly tolerated.
The treatment of tic disorders involves education of the child and the family about the condition, advice to parents on how to deal with behaviour problems, counselling and structured problem solving to deal with stressors, treating co-morbid condition, and the use of medication to suppress the tics. Pervasive developmental disorders
These disorders are characterised by severe impairments in social interaction and communication skills, and the presence of stereotyped behaviours, interests and activities. It is desirable for the general practitioner to be confident in both making and excluding the diagnosis. As a key person in the coordination of the different aspects of care, the general practitioner should also be familiar with the range of treatment and rehabilitation services available.
It is desirable for the general practitioner to be confident in both making and excluding the diagnosis of a pervasive developmental disorder.
In his initial description of autism in 1943, Kanner focused on how deficits in social interaction are sometimes accompanied by areas of unexpected competence such as rote memory2. Unfortunately, he also hypothesised that the condition was caused by abnormal patterns of
Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd Edition, North Melbourne,Victoria, Therapeutic Guidelines Ltd. 1995. 2 Kanner L. Autistic disturbances of affective contact. Nervous Child 1943; 2:217-250.
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family interaction. He later revised this theory, recognising that abnormal family interactions were usually an effect rather than a cause of the condition. The disorder has, from the outset, been the subject of conflicting views and controversies that are a further source of distress for parents coming to terms with their childs chronic and disabling condition. Are sufferers in fact people of exceptional ability held captive by their illness? What are parents to make of the claims of the latest fad cure (for example, through diet, avoidance of allergens, or hugging and holding)? Does aversive conditioning have any role in treatment? It is important for the general practitioner to be aware of empirically tested interventions and to be sceptical of the dramatic claims of unproven and often expensive approaches to treatment. The condition has a life-long course. It can result in profound disability and handicap for the individual sufferer and considerable stress for family members. There is no cure. Instead, treatment aims to minimise individual suffering and disability, to promote development, and to support families in coping with their disabled family member. Assessment and diagnosis In Australia, the diagnosis of a pervasive developmental disorder is usually made by a child psychiatrist or a paediatrician. The complete assessment is multi-disciplinary. A paediatrician will perform a physical examination and arrange appropriate investigations, including a search for Fragile-X chromosome and an audiological assessment. Cognitive function will be assessed by a psychologist using an instrument such as the WAIS-R 4th edition. A speech pathologist will assess communication ability. An occupational therapist or physiotherapist will evaluate sensory and motor integration. Using the DSM-IV criteria, the most serious disorder, autistic disorder, requires symptoms from each of the following three categories1: 1. Impairment in social interaction There may be limited nonverbal behaviours; a failure to make friends; no interest in sharing activities with others; and a lack of reciprocity in social interactions. 2. Impaired communication There may be a delay in, or a total lack of development of spoken language; an inability to initiate or sustain a conversation with others; stereotyped and repetitive use of language; or a lack of age appropriate spontaneous make-believe or social imitative play. 3. Restricted repetitive and stereotyped patterns of behaviour, interests, and activities These include a preoccupation with one or more restricted patterns of interest; inflexible adherence to specific, non-functional routines or rituals; motor mannerisms; and a preoccupation with parts of objects. Some examples of these impairments, and some commonly associated features, are listed in Table 24-2.
The diagnosis of autistic disorder requires symptoms of impaired social interaction, impaired communication, and the presence of restricted repetitive and stereotyped patterns of behaviour, interests, and activities.
In contrast to autistic disorder, language development is not delayed in Aspergers disorder (i.e. single words are used by the age of two years, and the child communicates in phrases by age three). Nor are there significant delays in cognitive development, or in the development of ageappropriate self-help skills, adaptive behaviour (other than in social interaction), and curiosity about the environment1. However, despite having normal language development, the higher-
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Ed. Washington DC: American Psychiatric Association, 1994. 2 ibid.
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level communication skills of these children are usually impaired, i.e. understanding metaphor and humour and the ability to modulate tone of voice appropriately. Differential diagnosis In contrast to autism, schizophrenia usually develops after a period of normal development and requires the presence of specific psychotic symptoms. In selective mutism, the communication difficulties are restricted to specific situations. Children with language disorders lack the impairments in social interaction and do not exhibit the repetitive stereotyped behaviours of pervasive developmental disorders. An additional diagnosis of autism is only made in children with mental retardation if the specific deficits in communication and social interaction and specific stereotyped behaviours are present. Co-morbidity Around 75 per cent of autistic children suffer mental retardation. By age 20, approximately one third have suffered an epileptic seizure.
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General practitioners are well placed to coordinate the care of individuals with pervasive developmental disorders.
Education The education of children with a pervasive development disorder focuses on the acquisition of daily living skills, with special emphasis on improving the primary deficits in communication and social skills. Where possible, teaching is incorporated into naturally occurring activities. Within the classroom, autistic children often respond better to visual images than to words. Communication therapy Following an assessment of how, what and with whom the child presently communicates, therapy seeks to extend the childs ability to communicate with others. Initially, nonverbal communication by use of gestures and objects may be used. Pictures and other visual representations may be used to introduce the spoken and written word. The use of facilitated communication in which a person assists the child in pointing to letters on a board is controversial. It has been repeatedly shown to reflect communication of the facilitator rather than the child. In some cases, parents have been accused, though never convicted, of child sexual abuse on the basis of facilitated communication. Behaviour therapy The behaviour therapies outlined in the section on parental advice are used in managing some of the difficult behaviours exhibited by these children. Parents need to be aware of the limited capabilities of these children, especially those who also suffer mental retardation. In addition, there is also a place for the use of aversive procedures for the management of self-destructive behaviours. Pharmacological therapy A balance must be achieved between symptom reduction and the adverse side effects of medication, especially sedation. It is therefore essential, prior to commencing treatment, to
Tonge BJ, Brereton AV. Australia. In: Cohen DJ,Volkmar FR, eds. Handbook of Autism and Pervasive Developmental Disorders. 2nd Ed. New York: John Wiley, 1997: 951-956.
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carefully monitor baseline behaviours and set specific targets for symptom reduction, and to review the efficacy of treatment on this basis. Parents, teachers and other adults involved in the childs care should be consulted in setting the goals of treatment and in assessing its outcomes.
When prescribing medication, a balance must be sought between symptom reduction and the adverse effects of medication.
Until recently, the most commonly used drug was haloperidol, which is effective in reducing stereotypies, hyperactivity, distractibility and aggressive behaviour. Recommended doses begin with 0.250.5mg orally per day, increasing if necessary up to 0.05mg/kg/day orally1. Side effects include sedation, acute dystonia and dyskinesias. On cessation of the medication, dyskinetic symptoms have been reported to disappear in between a week and eight months. Because of its more favourable side effect profile, risperidone is now used more often. Other agents that have been used include fenfluramine, naltrexone, tricyclic antidepressants, beta blockers, clonidine, buspirone and SSRIs. I recommend referral to a child psychiatrist for advice on prescribing these. Social skills training The aim of social skills training is to make children with pervasive development disorders more aware of the needs of others, to teach them to play, and to increase their interest in social interaction. Training groups often involve the participation of other children in shared, pleasurable activities that do not require complex communication. Programs also aim to improve communication skills in social situations. Individual therapy Because of the communication problems, it is difficult to form a therapeutic alliance with people with pervasive development disorders. However, for those with adequate language skills, attempts should be made to understand the interests and views of the child. A balance is sought between acknowledgment and validation of the childs perspective, and helping him or her to meet the demands of the environment. A goal of therapy is to help children gain an understanding of their disability, how they differ from other disabled children, and how they can gain assistance. The techniques of supportive psychotherapy are generally applicable (see Chapter 8). The principles of counselling and structured problem solving described in Chapter 6 can be used to help the sufferer deal with the stressors of everyday life. In particular, you may need to explain the consequences of intended actions that the sufferer has not anticipated. Family issues Having an autistic child in the family is stressful to parents and other family members. Moreover, parents are often confused by conflicting advice over diagnosis, prognosis and treatment, in particular over claims of the latest fads in treatment. They may be puzzled by the uneven development of the child across different skill areas. For example, the child may have normal visio-spatial and motor skills, but deficits in language and social interaction. They may be uncertain whether a childs behaviour problems represent oppositional behaviour or an inability to understand what should be done. Unlike children with other disabilities, the autistic childs normal appearance often belies his or her disabilities. Parents may be embarrassed by difficult behaviours in public. The key interventions are education about the illness and about child development. Parents may benefit from learning the behavioural approaches described in the section on advice on parenting. Teach structured problem solving to help parents deal with the stress of having a disabled child, and with intercurrent stressors. Refer parents to relevant community organisations that offer support, advice, assessment, treatment and respite.
Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd Edition, North Melbourne,Victoria, Therapeutic Guidelines Ltd. 1995.
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Non-government organisations Autistic associations in each state provide education, therapy, support and training services to people with autism, autism spectrum disorder (ASD) and Aspergers syndrome, and to their families and others involved in their care. Employment The majority of sufferers will not find work in open employment. Supported employment options include sheltered workshops, and situations in which a supervisor accompanies one or a small number of clients to the workplace. Residential options Most children with a PDD live with their parents. In Queensland, respite services are available through the Intellectual Disability Services and the Autistic Association Queensland.
Anorexia nervosa
The diagnosis of anorexia nervosa is made on the basis of a refusal to maintain normal weight (more than 15 per cent below that expected); fear of gaining weight or weight phobia; disturbance of body image (i.e. perceiving ones emaciated body as fat); and amenorrhoea. The DSM-IV recognises two types of the disorder. In the binge eating type, the sufferer regularly engages in binge-eating or purging behaviour (i.e. self-induced vomiting or the misuse of laxatives, diuretics or enemas). In the restricting subtype, weight loss is accomplished through dieting, fasting or excessive exercise. Differential diagnosis Unlike those with anorexia nervosa, people with bulimia nervosa are able to maintain their weight at or above normal levels. It is important to exclude physical conditions that can cause weight loss, including cancer and brain tumours. Depressed young people may suffer weight loss as a result of poor appetite, but they do not have the specific body image disturbance and fear of obesity characteristic of the person with anorexia. Appetite is usually only decreased in anorexia when there is severe weight loss. The agitation of the depressed person may be confused with the over-activity of the person with anorexia nervosa. Epidemiology The disorder predominantly affects females among whom the prevalence is around one per cent. Anorexia nervosa is rare in boys and is associated with a poor prognosis. While the prevalence among females appears to have been falling over recent years, the prevalence in young men may be rising. Although the condition of anorexia nervosa is rare, dieting among adolescent girls is very common. The peak age of onset for anorexia nervosa is between 15 and 17 years. The diagnosis is rarely made before puberty. Family pattern There is an increased incidence of anorexia nervosa and mood disorders among first-degree relatives. Complications The disorder may be complicated by depression. Cognitive changes produced by starvation include a preoccupation with food, and a concrete, black and white style of thinking.Those who have a pattern of purging and binge eating may exhibit other impulse control problems such as substance abuse. They are especially prone to suffering mood disorders.
Cognitive changes produced by starvation include a preoccupation with food and a concrete, black and white style of thinking.
Physical complications include amenorrhoea, electrolyte abnormalities, anaemia, bradycardia and other arrhythmias, cold intolerance, hypotension, hypothermia, the development of lanugo hair,
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and osteoporosis. Complications of purging include loss of dental enamel, calluses on the hands and parotid enlargement. Persistent laxative abuse can lead to constipation and megacolon.
Physical complications of purging include electrolyte abnormalities, cardiac dysrhythmias, loss of dental enamel, calluses on the hands and parotid enlargement.
Prognosis About 40 per cent of people recover fully, another 40 per cent recover to some degree, and the remaining 20 per cent follow a chronic course. The long-term mortality rate in patients admitted to university hospitals in the USA is over 10 per cent. Poor prognostic indicators include chronicity, older age at onset, very low weight, the presence of bulimia and vomiting, and poor childhood adjustment. Formulation A comprehensive bio-psychosocial formulation is required for each individual. Biological factors Evidence from family and twin studies demonstrates some genetic predisposition to the condition. The effects of starvation itself may perpetuate some of the behaviours typical of the condition. Psychological factors A pervasive sense of powerlessness coupled to an intense desire to exert control is an important psychological characteristic of the condition. The strict adherence to a diet can be seen as a way of maintaining control at a time when the girl is facing the many changes and demands of adolescence.The dieting itself may cause amenorrhoea and arrest physical development. Starvation tends to accentuate a rather rigid, black and white, concrete cognitive style. Paradoxically, the starvation also causes a compulsive preoccupation with food, calorie counting, and cooking.
The anorexic girls strict adherence to a diet can be seen as a way of maintaining control at a time when she is facing the many changes and demands of adolescence.
Social factors Social factors in the aetiology of anorexia nervosa include societal expectations that young women should be thin. The families of some young people with anorexia are characterised by patterns of over-involvement, rigidity, a diminished expression of affect, a lack of conflict resolution and a high emphasis placed on achievement. However, it is often unclear whether these are a cause or effect of the illness. Food is often an important means of communication within these families, and it becomes the vehicle for the girls rebellion and the means through which she seeks to establish a sense of autonomy from the family.There is an increased incidence of eating disorder, affective disorder and alcoholism in the families of women with anorexia. Treatment In many cases, treatment can be managed on an outpatient basis. Following are some principles of treatment: 1. setting a target weightfor example, ideal body weight or BMI of 2025 (see Table 24-3) 2. forming a therapeutic alliance and reaching an agreement with the girl to increase weight by one kg/per week until ideal body weight is reached 3. coordination with a dietician who can advise on a diet that will produce a steady weight gain 4. as weight is gained, dealing, in individual therapy with psychological and social issues that
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come to the fore, including adolescent conflicts over identity, autonomy and sexuality 5. family therapy to address issues of separation and autonomy, dealing with adverse emotional reactions (guilt, shame and anger), counselling and structured problem solving to address conflicts and other stressors within the family 6. indications for inpatient care include: rapid weight loss extreme weight loss (hospital admission is advised if weight falls below a BMI of 16) electrolyte disturbance, especially in the person who has concurrent bulimia and vomiting (death may result from hypokalemia) severe depression with suicidal intent.
Bulimia nervosa
The disorder is characterised by episodes of binge eating and compensatory behaviour to prevent weight gain. A binge is an episode in which a large amount of food is consumed in a short period of time, accompanied by a sense of loss of control. Compensatory behaviours include self-induced vomiting; misuse of laxatives, diuretics, enemas or other medications; fasting; and excessive exercise. The persons self-esteem is strongly influenced by her evaluation of her body shape and weight. Differential diagnosis The disorder needs to be distinguished from neurological disorders (including epilepsy and CNS tumour) and schizophrenia. Unlike those with anorexia nervosa, people with bulimia nervosa are usually within the normal weight range or slightly overweight.Whereas those with anorexia nervosa of the restricting type tend to be excessively controlled and rigid in their behaviour, people with bulimia often have difficulty controlling their impulses. In addition to bingeing, this lack of control may be manifest in substance abuse, promiscuity and self-harming. Between 30 and 50 per cent of sufferers have features of personality dysfunction, most commonly, borderline personality disorder.
Whereas people with anorexia nervosa (restricting type) tend to be excessively controlled and rigid in their behaviour, those with bulimia often have difficulty controlling their impulses.
Epidemiology Bulimia is a disorder of Western industrialised countries. Ninety per cent of sufferers are female. The prevalence among adolescent girls and young women is between one and three per cent. Course The disorder usually begins in late adolescence or early adulthood. It often persists with intermittent exacerbations and remissions occurring over a number of years. Complications The disorder is associated with depression, personality disorder, anxiety disorders and substance abuse.
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Mental disorders commonly associated with bulimia include depression, personality disorder, anxiety disorder and substance abuse.
Medical complications include loss of dental enamel and parotid enlargement due to selfinduced vomiting. Menstrual irregularities may occur. Fluid and electrolyte disturbances may be complicated by cardiac arrhythmias. Rare complications include oesophageal tears and gastric rupture. Family pattern There is an increased incidence of bulimia nervosa, mood disorders and substance abuse in the relatives of people with bulimia nervosa. Treatment Therapeutic alliance Building a therapeutic alliance is often difficult. Sufferers are often secretive about their bingeing and ambivalent about abandoning their symptoms. Alternatively, they may have unrealistic expectations of rapid cure. Monitor for complications Check for the physical complications. In particular, serum electrolytes should be monitored in the young woman who is purging.
Use counselling and structured problem solving to identify and cope with current stressors.
Use cognitive behavioural techniques to correct cognitive distortions.These commonly include black and white thinking, such as All sweet food is bad. Therefore, I can only eat low-calorie food; over-emphasising the negative, I have put on one kilogram so I might as well give up or I have eaten a cake. Therefore I have no control; magical thinking, Anything sweet goes straight to fat; or mind reading, He doesnt speak to me. Therefore, he must think I am too fat (see also Chapter 10). Typical underlying assumptions include the belief that one must be approved of by others to be a good person, and more specifically, that others must approve of ones body shape and weight. In challenging these assumptions, it is important to recognise the fact that many people in our society do place a high value on people being slim. The approach should be to challenge the
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validity of these attitudes and to help the individual accept that one does not have to be perfect and thin in order to be a good person. Some patients may need to deal with issues of past sexual abuse (see also Chapter 21). Family therapy Educate the family about the nature of the disorder and use the principles of counselling and structured problem solving to help the family deal with precipitating stressors. However, remember that adolescents will also need individual therapy, separate from their families. Behavioural approaches Ask the person to identify the cues to binge eating and help them find alternative responses. These might include avoidance (e.g. planning social activities to avoid long periods alone, taking another route home to avoid passing the delicatessen) or distraction (e.g. going for a walk, listening to music, performing a relaxation exercise). The principles of exposure and response prevention are also applicable (e.g. eating sweet foods without bingeing). Medication Antidepressants, especially SSRIs, may be of benefit, particularly if the person suffers comorbid depression. Do not prescribe tricyclic antidepressants to this group. Indications for specialist referral include: failure of the above treatments severe family psychopathology severe co-morbid disorders such as depression, substance abuse, borderline personality disorder medical complications of the disorder a history of past sexual abuse. Indications for hospitalisation include: BMI below 16 chaotic eating and uncontrollable vomiting electrolyte disturbance hematemesis emaciation severe depression suicidality.
being always on the go, and talking excessively. Signs of impulsivity include blurting out answers to questions, difficulty waiting turn, and constantly interrupting. For the diagnosis to be made, these symptoms need not merely to be present, but to be present often. Associated features include low self-esteem, labile mood, temper tantrums, academic underachievement, and accident proneness.
The diagnosis of ADHD requires persistent patterns of inattention, hyperactivity and impulsivity with some symptoms presenting before age seven.
There are no specific laboratory findings. The positive and negative predictive values of various complex and expensive tests are too low to be useful. There are no specific findings on physical examination.
It is important to distinguish between the symptoms of ADHD and age appropriate behaviours in active children, or in children under stress.
Treatment Non-pharmacological interventions include parenting advice (see pp 259264), behavioural interventions (see Chapter 9), family assessment, support and counselling (see Chapter 5), problem solving (see Chapter 6), and the provision of practical advice such as the availability of respite. The roles of the general practitioner include making a thorough biopsychosocial assessment of the presenting problems, referring likely cases for specialist assessment, and coordinating the different professionals involved. The assessment and treatment of ADHD is usually multi-disciplinary with a child psychiatrist or paediatrician confirming the diagnosis and advising on the use of medication. A psychologist
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will often perform a neuro-psychological assessment, provide baseline measurement of target symptoms, and formulate a behaviour program. Audiometry, dietary advice and family therapy may be indicated. It is essential to liaise closely with the childs teacher and to provide clear written instructions if medication is to be dispensed at school. Biological treatments include methylphenidate (Ritalin) at a dose of between 0.3mg and 0.8mg/ kg/day, or dexamphetamine 0.150.4 mg/kg/day, in divided doses, in the morning and at midday. The duration of effect is around four hours, but with considerable individual variation1. Side effects include abdominal discomfort, decreased appetite, insomnia, headache, irritability, depressed mood, a delay in the height and weight spurt at puberty, and the risk of amphetamine abuse. There may be a rebound of symptoms as the medication starts to wear off in the evening. Stimulants may worsen tics. Drug holidays may be advisable over weekends or during school holidays. A trial without medication during the school term is advisable after 612 months of therapy.
Methylphenidate is prescribed in doses of 0.30.8 mg/kg/day, in divided doses, in the morning and at midday. Doses of dexamphetamine are between 0.15 and 0.4 mg/kg/day.
Tricyclics and clonidine are sometimes used in the treatment of ADHD. I recommend seeking specialist advice before prescribing these. If medication is prescribed, it is advisable to document outcome using an instrument such as the ADHD Rating Scale administered before and after a trial of treatment2. One of the childs parents and a teacher are asked to complete the rating, indicating the frequency of each symptom on the Likert scale by selecting the single item that best describes the child.
Conduct disorder
The diagnosis of conduct disorder is made on the basis of a pattern of behaviours that violate the norms of our society and the rights of others. Such behaviours include aggression to people and animals, destruction of property, deceitfulness and stealing, and other serious violations of the rules. These behaviours cause significant handicap at school, at work and in personal relationships. Differential diagnosis The behaviours are more serious than in oppositional defiant disorder and include those that infringe the rights of others, aggression towards people and animals, property destruction, theft and deceit.The recent onset of antisocial behaviour in a previously well-behaved child raises the possibility of depression, mania or substance abuse. Aetiology and associated conditions Antisocial behaviour tends to run in families.Associated conditions include criminality, alcoholism (especially in fathers) and somatisation (especially in mothers). Social factors in the aetiology of conduct disorder include parental discord and antisocial behaviour in parents. Psychological factors include deficits in the capacity to experience guilt or remorse; a failure to see rules as important; an inability to understand the consequences of ones actions, including their impact on others; and a lack of mutuality and reciprocity in relationships. Developmental problems are often evident, especially in more severe cases. Low IQ and impaired attention, concentration, memory and abstraction may be found. These may in turn be the result of an injury sustained during a violent and chaotic upbringing.
Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd Edition, North Melbourne,Victoria, Therapeutic Guidelines Ltd. 1995. 2 See Appendix 13.
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Epidemiology The disorder is present in between four and 10 per cent of children and adolescents. The rate is twice as high in boys than in girls. Prognosis The prognosis is fair to poor. It is the most stable of childhood diagnoses over time.The disorder may progress to antisocial personality disorder in adulthood. The death rates for conductdisordered youths are about 50 times those for normal youths. Deaths occur through accidents, suicide, homicide (especially in the US) and drug overdose. Assessment In addition to an assessment of the childs difficult behaviours, it is important to note his or her social strengths, as these form the basis upon which progress can be made. Family issues are important. Are the problematic behaviours modelled on those of other family members? How do families respond to antisocial behaviours? What is the state of the parents marriage? Are the parents united in their approach to dealing with the problems? Treatment As a group, these are probably the most difficult conditions in child and adolescent psychiatry to treat. The children rarely present themselves for treatment, but rather are brought to see you at the insistence of schoolteachers, community agencies, the courts or parents. Transference issues arise quickly, particularly in those who feel most helpless. These young people may act out in the consultation by manipulation, stonewalling or even by making threats. Psychosocial Treatments Only children with the milder forms of conduct disorder respond favourably to outpatient counselling. For the more severe cases, behavioural programs with firm limits and predictable consequences for misdeeds are required. Caregivers must be able to cooperate with the behavioural program. Advise them to change coercive and inconsistent methods of discipline. Encourage them to set rules, negotiate compromises, and offer concrete rewards for behaviours that help others. Family sessions may be used to clarify patterns of communication, to help family members recognise certain behaviours, and to teach problem solving (see also section on advice on parenting, pp 259264).
Enlist the support of parents in programs that aim to improve a childs behaviour.
In the countertransference, it is wise to avoid over-reacting to the childs problematic behaviours. It is the child who must learn self-control. Focus on concrete issues, using counselling and structured problem solving. While psychodynamics may help you understand the problems, the interpretation of defences and other techniques of psychodynamic psychotherapy are generally not useful. Give parents clear advice and support. Drug treatments The prescription of drugs in this group is fraught with difficulties. Drugs may be hoarded, sold or taken in overdose. It is probably best to seek specialist advice before prescribing any drugs to these young people.
Drugs prescribed to adolescents with conduct disorders may be hoarded, sold, abused or taken in overdose. Oppositional defiant disorder
This disorder is characterised by a persistent pattern of negativistic, disobedient, hostile and defiant behaviour towards parents, teachers and other authority figures. The child often loses
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his or her temper, argues with adults, defies adults requests, deliberately annoys people, blames others for his or her mistakes, is easily annoyed by others, and is often angry, resentful, spiteful and vindictive. Associated features include irritability and mood disorder, low self-esteem, low frustration tolerance and the precocious use of substances. Differential diagnosis Some oppositional behaviour is a normal part of the development of a childs autonomy. It is only pathological if it is frequent, severe, and causes significant disability and handicap. The behaviours are not as severe as those found in conduct disorder. Unlike conduct disorder, the syndrome does not usually include aggression to people and animals, property destruction or a pattern of theft and deceit.The onset of oppositional behaviours in children and adolescents who have had no previous behaviour problems raises the possibility of depression, anxiety disorders, psychotic disorders or substance abuse. Epidemiology The prevalence has been estimated to be between 2 per cent and 16 per cent1. The disorder is more prevalent in boys before puberty, but the rates are thought to be equal in young men and women after puberty. Familial pattern In the families of children with the disorder, there are increased rates of depression, antisocial personality disorder and substance abuse. Parents may have a history of conduct disorder, ADHD or oppositional defiant disorder. The disorder is more common in families with marital discord.2 Course and prognosis The symptoms usually appear before the age of eight years. The oppositional symptoms are almost always evident at home, but may also appear at school and in other situations. It may develop into conduct disorder.
Unlike conduct disorder, the syndrome of oppositional defiant disorder does not usually include aggression to people and animals, property destruction, stealing or other serious illegal activities.
Treatment Parents are offered advice on managing the difficult behaviours (see Parenting Advice, pp 259264). In individual therapy, children can express their autonomy in a non-controlling environment. The therapist can also diagnose and treat co-morbid depression, low self-esteem, substance abuse or psychosis.
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female cohort. Australia has the highest rate of suicide in young people in the world. For 15 to 24 year olds, the rate is 16.4 per 100,000 per year. Queenslands adolescent suicide rate is two per cent above the national average (18.4/100.000).
Suicide is currently the leading cause of death in males between the ages of 15 and 24 years.
Adolescent males living in rural areas have a higher suicide rate than do the corresponding urban cohort. Moreover, these rates are increasing. In 1986 the rate of suicide among young males from rural areas was 24/100,000. By 1992 the rate had reached 36/100,000. The corresponding urban rates in 1986 and 1992 were 21/100,000 and 26/100,000 respectively. The reverse trend applies for females, with figures for urban areas being slightly higher (5/100,000) than for rural areas (4/100,000). Assessment and diagnosis Depressed children and adolescents present with somewhat different symptoms and signs than do depressed adults. Children may have difficulty describing their mood and present instead with somatic symptoms.Their parents may bring them to see you because of behavioural problems aggression, withdrawal, deterioration in school performance, disruption of peer relationships or school refusal. The predominant mood may be irritability rather than depression. Anger, often directed at parents, may be a feature. Determine whether there has been any loss of interest or pleasure in their usual activities (anhedonia). Begin by asking about their hobbies and interests, and then assess whether there has been any recent change in their participation in these activities. Ask when they last did something they really enjoyed. Poor concentration may lead to deterioration in school performance. Assess the level of hopelessness by asking about plans for the future. Listen for statements that no one can help or nothing can help and other evidence of helplessness. Ask about neurovegetative symptoms insomnia, poor appetite, weight loss, diurnal mood variation and low energy levels. Observe any psychomotor retardation or agitation. Depressed young people frequently suffer co-morbid anxiety symptoms, including panic attacks, obsessions and compulsions. Rarely, there may be psychotic symptoms (e.g. hallucinations or delusions). Ask a depressed young (man) about any ideas he has of suicide or self-harm, but be prepared to follow up with a discussion of alternative ways of problem solving (see following ). The commonest diagnosis, especially in children between 8 and 11 years old, is dysthymic disorder, rather than major depression. This syndrome is characterised by depressed or irritable mood on most days of the week over a period of at least one year.While the symptoms may not be as severe as in major depression, the level of disability and handicap, manifest by poor school performance and problems with peers and family, is often high. It is often associated with a low self-esteem and a perception of being unloved by parents, siblings, peers, teachers and others in the social environment. It may be complicated by the development of major depression in adolescence.
In children between the ages of 8 and 11 years, the commonest depressive syndrome is dysthymic disorder, characterised by chronic depressed or irritable mood, low self-esteem and a perception of being unloved.
Differential diagnosis Physical disorders and substances that can cause depression are listed in Tables 17-5 and 17-7. As mentioned above, anxiety symptoms often occur in depressive disorders. It is important to distinguish the agitation of depression from the restlessness of ADHD. The first onset of symptoms in a child who previously had no behaviour problems is unlikely to be due to ADHD.
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In older children and adolescents, consider the diagnosis of a psychotic disorder. Formulation Biological factors that should be considered in the formulation of a young person with depression include underlying physical illness or substance abuse, and a family history of affective disorder (especially bipolar disorder). Psychological factors to consider include any past history of depression, substance abuse, conduct disorder or self-harm. Social factors include family, school or relationship problems. Parental separation and divorce, mental illness in a parent (especially alcoholism, depression and suicide), and physical, emotional or sexual abuse is associated with the development of depression in young people. Children with dysthymic disorder often perceive that they are unloved. Treatment This will depend on the individual formulation.The first step is to form an effective therapeutic alliance with the young person and the family. Educating the child and the family about depression, its symptoms, causes, prognosis and treatment will often, in itself, provide some relief. It will also improve adherence to treatment and follow-up. Deal with any family problems that are uncovered in the assessment. This might, for example, include the treatment of a depressed parent. Use the psychological therapies described in Chapters 6-12. In treating young people, you will have to see the individual alone and together with the rest of the family. Cognitive behavioural treatment is effective in the treatment of mild to moderate depression, including dysthymic disorder. Aim to minimise the disability and handicap associated with the depression. For example, if school refusal is a feature, insist on a return to school. It may be necessary to enlist the support of parents and teachers to ensure that this occurs.
Be prepared to follow up an inquiry about suicidality with a discussion of alternative problem solving strategies.
Try to distinguish ideas of self-harm from ideas of suicide. Ask what the child believed was the risk of dying. Ask whether the plan included any ideas of being rescued. Assess a childs understanding of death and its permanence by asking what he or she expects to happen after death. Suicidal and self-harming behaviour are maladaptive solutions to problems in the young persons life. Try to identify the precipitating problem. Many suicides and suicide attempts occur in the context of relationship problems. The meaning of suicide may, in some cases, be to send a message, often an angry message, to someone important in that persons life. The risk of suicide is higher if someone known to the young person has committed suicide. In some cases, problems over sexual orientation may lead an adolescent to contemplate suicide. Determine the nature of the underlying mental disorder.The commonest diagnosis is depression. In particular, you should assess hopelessness by asking what the young person sees for the future. Other disorders associated with an increased risk of suicide include anxiety disorders, alcohol and other substance abuse, conduct disorder and psychosis.
Disorders commonly associated with suicidal ideation and behaviour include depression, anxiety disorders, alcohol and other substance abuse, conduct disorder and psychosis.
Assess the availability of means, in particular the young persons access to firearms. Ask about any previous suicide attempts, their frequency and lethality, and their motivation. Assess the level of disability and handicap by asking about functioning at home, at school and with peers. Interview the family to obtain collateral information. Many depressed children believe that they are to blame for family problems. In some cases, parents may consciously or unconsciously promote such a belief. On the other hand, family support and cohesion, shared interests with other family members, and family support are protective. Treatment and prevention of suicidality The cornerstone of treatment is the accurate diagnosis and treatment of the underlying mental (or physical) disorder. Take steps to limit the young persons access to the means of committing suicide, in particular to lethal means such as firearms. Reach an agreement with the child and his or her family and carers to seek help before self-harming. Use counselling and structured problem solving techniques to deal with the precipitating problem. Mobilise family and social networks to provide support. Refer for specialist assessment if no safety agreement can be made, if there is severe family disruption or if the child is suffering severe depressive symptoms. See Chapter 3 for a more detailed description of these issues.
Anxiety disorders
An anxiety disorder is present when the normal fight and flight response to a threatening stimulus is exaggerated, if it occurs at times when there is no realistic threat, or persists after the threat has been removed. The diagnosis may be associated with particular patterns of disability and handicap.The physical symptoms may be taken as evidence of a medical condition and lead to extensive physical investigations. It may be associated with school refusal, which may in turn be reinforced by the secondary gains of staying at home. School refusal causes significant disability and handicap academic problems, a loss of friends and becoming the victim of bullies. The child who reacts to minor stimuli with a fight/flight response may be seen as disobedient. Insomnia may lead to fatigue, irritability and a deterioration in school performance. The childs condition will
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also have an impact on other family members. See also Chapter 15 for a detailed discussion of anxiety disorders.
Disability and handicap associated with anxiety disorders include school problems, school refusal, insomnia and family problems.
Diagnosis The history is gained from both the child and his or her parents. Useful collateral may be obtained from schoolteachers and others with whom the child has contact. On the mental status examination, the child may be tense, shaky, vigilant and quick to startle. Observe how the child manages to separate from his or her parents. In addition to the adult syndromes discussed in Chapter 15, the DSM IV includes Separation Anxiety Disorder as an anxiety disorder specific to childhood and young adolescents. It is characterised by excessive anxiety on separation from home or those to whom the person is attached. The differential diagnosis includes the abuse of substances (including caffeine), thyroid and other endocrine disturbances, anaemia, and cardiac abnormalities. There may be anxiety about unwanted pregnancy, or of having contracted a sexually transmitted disease. Anxiety disorders are often co-morbid with depression. In conduct disorder, the child may stay away from home or play truant from school, but has no anxiety about the separation.The diagnosis of a particular anxiety disorder is often difficult, as a young person may present with features of several disorders. Anxiety symptoms may also complicate other Axis I disorders such as ADHD. Treatment The treatment of anxiety disorders in children and young people follows the same principles as the treatment of adults (see Chapter 15). Some examples are given below. Behavioural techniques 1. Relaxation Example:A youth with generalised anxiety symptoms is informed about the nature of anxiety, taught controlled breathing, progressive muscular relaxation, advised how to use a relaxation tape, and taught a self-hypnosis technique (see Appendices 4-6). 2. Exposure Example: A nine-year-old girl who has a phobia of dogs is educated about the nature of anxiety and, in particular, about the problem of avoidance behaviours. She is taught a relaxation technique and is then progressively exposed, initially to pictures of dogs. In the final session, she is able to pat a dog in the session. At each step, she is encouraged to stay in the room with the therapist, using the relaxation technique, until her level of anxiety falls (habituation). 3. Modelling Example: An eight-year-old boy with needle phobia has his anxiety symptoms explained, as well as the purpose of the injection. He attends the appointment at which his older brother, who is not afraid of needles, has an injection. 4. Operant conditioning Example: An eight-year-old boy with behaviour problems is rewarded for good behaviour (e.g. doing the dishes, tidying his room, taking his younger sister for a walk) by being taken to the cinema with his father (positive reinforcement). When he has a temper tantrum, he has time-out in his bedroom (negative reinforcement), and when he hits his sister, he is admonished (punishment).
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5. Cognitive-behavioural treatment Example: A 13-year-old girl suffers symptoms of anxiety and depression. After assessing the problems and documenting the levels of anxiety and depression using rating scales, you explain the treatment and contract to see the girl for 12 sessions, once a week, over the following three months. The girl is asked to keep a diary of the negative thoughts that she has at times when she is feeling anxious and depressed. In the sessions, you challenge the faulty logic behind these thoughts. Later, the girl is asked to challenge the thoughts herself, both in the sessions and at times when she is suffering symptoms. She documents these in her diary and rehearses possible responses within the sessions. At the end of 12 weeks, the rating scales are again administered to assess the efficacy of treatment. 6. Other treatments Although the primary treatment modality may be behavioural or cognitive-behavioural, psychodynamic principles will often inform therapy. Example: A three-year-old girl continues to suffer nightmares, bed-wetting and separation anxiety nine months after her parents separated. She frequently sleeps in her mothers bed and she becomes very upset whenever her mother goes out. The girl, who has always been pleasant, considerate, and friendly in play therapy, suddenly becomes angry while hammering pegs through a wood block. She begins swinging the mallet around her head, narrowly missing the therapist, all the time cackling with laughter. The therapist stands up and quickly regains control. Comment: The childs anger with her father, previously repressed, is displaced on to the therapist and acted out. Family interventions are often required. A parent may suffer an anxiety disorder or other Axis I condition. Parents may reinforce a childs anxiety either by failing to give adequate support, or by intervening too quickly to remove a child from situations that cause anxiety. Abused children may present with anxiety symptoms, including those of post-traumatic stress disorder. Children who are too powerful within a family may be anxious (e.g. a girl with school refusal has to stay at home to support her mother who suffers delusions that the neighbours will kidnap her if she is left alone).
Check for the presence of mental health problems in the family members of children and adolescents with anxiety disorders.
Drug treatments may sometimes be used for specific symptoms. However, because of their uncertain efficacy, and their side effects and toxicity, I recommend referral of any young person requiring pharmacological treatment to a child psychiatrist.
Obsessivecompulsive disorder
Assessment and diagnosis The diagnosis of the disorder is based on the presence of obsessions and compulsions (see Chapter 15). The Childrens Yale-Brown ObsessiveCompulsive Scale (CY-BOCS) may assist assessment1. Between one and four per cent of children suffer obsessivecompulsive symptoms. Differential diagnosis The differential diagnosis includes normal age-appropriate rituals of childhood. These differ from obsessions and compulsions in their transience, and the lack of disability and handicap
Goodman WK, Price LH. Assessment of severity and change in obsessivecompulsive disorder. Psychiatric Clinics of North America 1992; 15:861-869.
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associated with them. Obsessions and compulsions frequently occur in the context of depression and other anxiety disorders. In a pure mood disorder, the mood symptoms will predominate. However, both disorders may coexist. Tics may be preceded by a premonitory urge, but unlike compulsions, they do not arise in response to an anxious thought or obsession. If the onset in abrupt, consider possible physical causes, including viral and bacterial infections, and substance abuse (especially amphetamine abuse). Co-morbidity The illness occurs most commonly together with other disorders with only around 25 per cent of symptomatic individuals suffering OCD alone. Common co-morbid diagnoses include tic disorders, depression, developmental disability, phobias and other anxiety disorders, oppositional disorder, ADHD and conduct disorder.
Obsessivecompulsive disorder occurs more frequently in combination with other disorders than it does alone.
Treatment Educating the family and the child about the nature of the illness will help establish a therapeutic alliance. Exposure and response prevention The cornerstone of treatment is exposure and response prevention (see Chapter 15).
Victorian Drug Usage Advisory Committee. Psychotropic Drug Guidelines, 3rd Edition, North Melbourne,Victoria, Therapeutic Guidelines Ltd. 1995. 2 ibid.
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Adjustment disorders
The reactions of young people to stress are complex. The quality of the adjustment will depend on the nature of the event itself, the context in which it occurs (e.g. how parents respond to the crisis), whether or not it precipitates chronic adversity (e.g. greater poverty), and the persons own personality and adaptation. Use counselling and structured problem solving to help the young person and his or her family deal with their problems (see Appendix 3). Divorce Divorce is usually preceded by a period of marital conflict and family discord, and may be followed by: parental conflict parental distress or illness changes of house and school loss of family income compromised relationships with either parent new parental relationships, including parental remarriage. Boys may exhibit more externalising behaviours, including irritability and aggression, than girls, but sex differences become fewer and perhaps more subtle as adolescence and young adulthood is reached. Some adolescents experience parental divorce as a foreshortening of the amount of time they have to grow up, and of being exposed and vulnerable. There is some evidence that as they approach young adulthood, the children of divorced parents experience more interpersonal relationship problems, including problems with intimacy. The severity of the problems may be correlated with high pre-separation parental hostility, an inability of the mother (usually the custodial parent) to form another stable relationship, and high levels of interference by one parent in the relationship of the child with the other parent after separation. In helping adolescents survive the process of divorce, use counselling and structured problem solving. Encourage agreement to sensitive arrangements concerning custody and access.
Child abuse
It is important to intervene early in cases of child abuse in order to limit the physical and psychological sequelae. The longer the abuse continues, the more severe the psychological damage done. People who were abused as children may enter into abusive relationships in adulthood, as victim or abuser. They are themselves at risk of becoming abusing parents. Consider the following types of abuse: Physical abuse usually involves excessive punishment for minor infractions, or for behaviour that is developmentally normal for the child. Emotional abuse may involve constant criticism, teasing and humiliation. Neglect is the failure to provide the childs basic needs for shelter, food, clothing and the other necessities of life. Emotional deprivation is the failure to provide the child with normal human contact, support and warmth. Sexual abuse involves the exploitation of a young person by an older person who is in a position of power over him or her.The perpetrator of the abuse may be a parent, sibling, other relative or acquaintance.
Abuse includes physical abuse (i.e. excessive punishment, or punishment for behaviour that is developmentally normal for the child), emotional abuse, emotional deprivation, neglect and sexual abuse.
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Evidence of abuse comes from a variety of sources. A third party may make allegations, the child may disclose the abuse, or the general practitioner may notice signs of abuse on physical examination. Physical abuse is most often identified on examination. In cases of sexual abuse, there are often no signs on physical examination. Identifying those at risk A number of risk factors for child abuse have been identified in populations of people. However, child abuse can occur in families with few apparent risk factors. Conversely, most parents at risk of abusing their children never do so.The presence of risk factors should raise your concern, but the starting point must always be evidence of abuse. The young mother who denies her pregnancy, seeks a termination of it, fails to prepare for the birth, and neglects her own health by smoking, drinking and abusing other substances, is at risk. Parents who were themselves abused as children are at higher risk, as are those who abuse drugs and alcohol and are facing multiple life stresses (e.g. financial, marital, and legal problems). Parents who abuse may take their child to see numerous different doctors, and provide vague explanations for injuries. Repeated presentations of a child with minor or vague complaints may be a call by the parent for help.
Parents at risk of abusing their children include young women with unwanted pregnancies, parents who were abused themselves as children, those facing severe life stressors and those who repeatedly present their children to doctors.
Children who suffer multiple accidents, and have a history of birth defects, failure to thrive, feeding problems and developmental delays are at higher risk. An abused child may perform poorly at school because of limited concentration. He or she may run away from home. Examination Observe the parents attitude towards the child and the way the child interacts with you. Note any absence of normal fear and pain responses. The child may behave in a pseudo-mature way and display inappropriate sexual knowledge or behave in a seductive manner. Carefully document the location, size and appearance of any injuries. The following injuries should arouse suspicion of physical abuse: 1. Fractures in children under nine months of age two or more fractures at different stages of recovery fractures in which the injury is inconsistent with the explanation given. 2. Bruises on the face or earlobes on the buttocks or thighs in the shape of a causative implement patterned bruises (e.g. grip marks) over soft areas as opposed to bony prominences. 3. Head Injury subdural haematoma retinal haemorrhages. 4. Burns immersion burns tap burns in unusual sites (i.e. non-contact areas).
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5. Closed abdominal injuries Abuse may be revealed in a childs drawings. The frightened child may assume an attitude of frozen watchfulness. Pregnancy in a young woman under the age of 16 years, or the diagnosis of venereal disease, raises the possibility of sexual abuse. Action It is mandatory to report cases of suspected child abuse in all states of Australia except Western Australia. Make yourself familiar with the legal requirements in your state. Have at hand a list of specialists whom you can contacta local paediatrician who is involved in child protection (in Queensland, this would be the person who sits on the local Suspected Child Abuse and Neglect panel, SCAN); the Department of Family Services; the police; and a crisis line (in Queensland: Crisis Care). If you are unable to contact any of the above, you can phone the major paediatric hospital in your state and speak to the paediatrician on call for suspected child abuse.
It is mandatory to report cases of suspected child abuse in all states except Western Australia.
While the factors mentioned above might raise the possibility of abuse, it is clinical evidence that you require in your assessment. It is not your role to investigate whether or not abuse has occurred, but rather to report and document as clearly as possible any findings suggestive of abuse, and to arrange appropriate treatment and referral. Try to be non-judgemental of the parents. In many cases, you will have to continue to support them and the child. Be open and explain that you are required under law to report any case of suspected abuse. This will deflect some of the parents anger away from you. It is generally advisable to interview both parents together. To separate them may only make them mistrustful, angry and uncooperative. A particularly difficult situation arises when allegations are made in the context of a custody dispute. Try not to take sides. Base your conclusions on the clinical evidence. Remember that it is not your job to decide guilt or innocence, but rather to report your clinical findings.
Advice on parenting
Parents often present to general practitioners for advice on managing their childrens behaviour. Parenting difficulties are stressful to parents. Positive management of a childs behaviour will improve his or her self-esteem and social functioning, and prevent problems in later life. The principles of successful parenting are based on learning theory (see Chapter 9). Under the operant conditioning paradigm, rewarding desirable behaviours increases their frequency, and escape from aversive stimuli increases the frequency of avoidance behaviour. Similarly, removing any inadvertent reinforcers reduces the frequency of undesirable behaviours. Social learning theory notes that children can learn both good and bad behaviours by observing others parents, siblings and friends. High arousal attenuates over time (habituation) and the intensity of responses diminishes on repeated exposure (desensitisation). Any attempt to modify a childs behaviour depends on the ability of the parent to communicate clearly with him or her. The childs attention must be gained, (e.g. by squatting down and speaking face to face with him or her). The communication must be clear, understandable and direct. The following discussion highlights some aspects of the Triple P positive parenting program, developed by the Parenting and Family Support Centre at the University of Queensland. Contact your local community health service for information on the referral of parents with persistent difficulties in managing their childrens behaviour to a Triple P group1.
Markie-Dadds C, Sanders MR, Turner KMT. Every Parents Self-help Workbook. Milton, Queensland, Families International Publishing 1999.
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Contact the local community health centre for information about the Triple P positive parenting program. Causes of behavioural problems
A childs temperament, including his or her sociability, emotional reactivity and level of activity is determined in part by genetic factors. Parents often observe a wide range of temperaments among their children. However, the behaviour of children is also influenced by a number of environmental factors over which the parents have some control. Parents should be asked to consider whether any of the following might be influencing their childs behaviour. Examples are given in Box 24-1.
Parents have control over a number of factors that can influence a childs behaviour
1. Accidental rewards Unwanted behaviours may be inadvertently reinforced, and so increase in frequency. 2. Escalation traps A childs difficult behaviour may escalate in an attempt to get what he or she wants. If the parent gives in, the child learns that escalating bad behaviour gets the desired result (it is positively reinforced). Parents may also fall into escalation trapthe boy learns that he only really needs to do as he is told when his father gets very angry with him. 3. Ignoring desirable behaviour Unless parents are attentive to their childs activities, they may miss opportunities to reinforce desirable behaviours. 4. Social learning Children learn by observing others. 5. Ineffective instructions Instructions may be ineffective for a number of reasons. There may be too many or too few of them. The child may not be able to understand them. The instructions may be ill-timed, too vague, or contradicted by the parents body language. 6. Emotional messages Parents may criticise the child rather than the unwanted behaviour. This may lower the childs self-esteem and make him or her feel angry, guilty and ashamed. 7. Inconsistent rules Rules will be ineffective if parents threaten certain consequences, but do not carry them out, or if the consequences are inconsistently applied. 8. Parents beliefs and expectations Parents may fail to discipline a child because they believe the child is just going through a normal phase of development. On the other hand, they may have expectations for the child that are beyond his or her developmental capabilities. Alternatively, they may blame themselves for all of a childs difficult behaviours. 9. Parental conflict Conflict between parents is often manifest by behaviour problems among their children. Parents need to work together as a team. Disagreements should be worked out away from the children.
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10. Parental illness and stress A mothers mental illness may impair her ability to discipline and care for her children. She will need extra support at this time. Parents who are under stress will have less time to attend to their childrens needs. All parents need breaks from the care of their children and time to themselves. 11. Factors outside the family Childrens behaviour is influenced by relationships with their peers, their ability to manage their schoolwork, and by their exposure to the mediatelevision, movies and computer games.
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How to be independent
Reproduced from Markie-Dadds C, Sanders MR, Turner KMT. Every Parents Self-help Workbook. Milton, Queensland: Families International Publishing, 1999, p14.
A useful approach for teaching children new behaviours is ask, say, do.
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Praising and otherwise rewarding a child when he or she performs a new action will increase its frequency. In some cases, it may be useful for the parents to draw up a chart of desired behaviours with agreed rewards.
Managing misbehaviour
The consequences of misbehaviour need to be clearly understood, immediate, consistent and decisive. Ask parents to consider the following suggestions. Examples are given in Box 24-3. 1. Set clear ground rules These should be limited to a few clearly defined and understandable rules. Rules are best stated in the positive (what the child should do), rather than the negative (what he or she should not do). 2. Directed discussion After gaining the childs attention, the parent should state the problem and the reason for it. The child should be asked to state the correct way of doing the task and then to do it properly. It may be useful to ask the child to repeat the action. On successful completion of the task, the child should be praised. 3. Ignoring minor infractions Minor problems such as whining, speaking in a silly voice or swearing are often best ignored. This does not apply to more serious problems, such as hitting another child. It is important that the parent continues to ignore the problem and does not respond to any escalation in the behaviour.
When a child is in quiet time, he or she is asked to sit quietly in the same room for a set period or time and ignored.
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7. Time out Time out is used to deal with more serious misbehaviourfor example, hurting other children, temper tantrums or refusing to comply with quiet time. The child is removed to another room and must remain quiet for a set length of time. The room must be safe and uninteresting. The child must understand the rules of time out. A childs behaviour may initially escalate when placed in time out. It is important that he or she is not let out while still upset, as this will only reinforce the unwanted behaviour. Time out begins from when the child becomes quiet. Time out is more effective than corporal punishment because as well as being effective, it teaches the child self-control.
A child in time out is removed to another room and must remain quiet for a set period of time. Forward planning
It is wise for parents to plan ahead for activities in which behaviour problems can be anticipated. This applies particularly to activities in which there is little for children to do. Parents are advised to take toys or other diversionary activities with them. They should discuss the ground rules for the childs behaviour beforehand. In some cases, there may be opportunities for incidental teaching. For example, on a long drive, parents can play I spy and discuss some of the things they see out the window. Parents should plan rewards for good behaviour, for example, getting an ice cream on arrival at the destination. Consequences for misbehaviour should be discussed and understood.
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Chapter 25
Doctors mental health
While medical practitioners are healthier overall and have a longer life expectancy than people in the general population, they suffer higher rates of alcohol and other substance abuse, mood disorder and death by suicide.Their marriages are subject to particular stressors and, like others in the caring professions, they are at risk of suffering burnout. The causes of this excess psychiatric morbidity include certain personality traits common among doctors, the stresses of the work, and the barriers that exist to adequate prevention and treatment. A number of facilities have been set up to deal with doctors mental health problems. General practitioners should be aware of steps that they can take to prevent developing mental health problems, and where they can get timely and effective treatment for themselves and their colleagues.
General practitioners need to be aware of steps that they can take to prevent developing mental illness, and where they can get timely and effective treatment for themselves and their colleagues.
Epidemiology
The rate of suicide among male doctors is comparable to that of males in the general population. The rates for females are reported to be similar to their male colleagues, or about four times that for women in the general population. Rates of depression amongst doctors are thought to be higher than in the general population, though this has recently been disputed1. Around 30 per cent of medical students suffer some emotional disturbance.This percentage increases during the period of training.The prevalence among junior doctors is reported to be as high as 50 per cent. Around seven to eight per cent of doctors drink to excess. The prevalence of substance abuse is around one per cent. Some addicted doctors may have begun using drugs to self-treat anxiety and depression, or as a maladaptive way of dealing with stress. Rates of divorce amongst female doctors are higher than for male doctors, and for women in the general population. Marital difficulties may contribute to or be a consequence of mental health problems. People working in the caring professions are at risk of developing the syndrome of burnout. Symptoms include feelings of fatigue, emotional exhaustion and apathy; a cynical attitude to work with feelings of futility and hopelessness; a loss of ones sense of humour; irritability and anger; avoidance behaviours, including a reluctance to see certain patients or difficulty going to work; clumsiness and frequent accidents; indecision and inefficiency; and persistent thoughts of resignation. The condition may be complicated by self-medication with alcohol or other drugs.
Compared with the general population, doctors suffer higher rates of completed suicide, substance abuse, marital problems and burnout. They may also suffer higher rates of depression.
Frank E, Dingle AD. Self-reported depression and suicide attempts among US women physicians. American Journal of Psychiatry 1999; 156:1887-1894.
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Stressors
General practitioners face the everyday difficulties of running a practice together with the particular stresses associated with clinical work. Everyday problems include overwork, having to rearrange appointment schedules and coping with interruptions. In an age of consumer activism, people expect to be fully informed about the services delivered and want greater involvement in decision-making. The rising cost of medical insurance reflects increasing rates of litigation. Doctors are envied for their high social status. They are often portrayed in the media as being greedy and overpaid. This can be particularly irritating for the general practitioner who has experienced the loss in status of the profession, and who is struggling to make a reasonable living. Unlike hospital specialists, general practitioners carry the full responsibility for their patients care on their own. They need to keep abreast of new knowledge, not only in a specific area, but also in the field as a whole. General practitioners working in a group practice face the interpersonal demands of dealing with their colleagues and ancillary staff. Clinical work is often very stressful. Doctors are exposed to the gamut of human suffering, including death and dying. They may hear stories of abuse and even torture. Some of their patients will be difficult and demanding.Treating colleagues and their families is often identified as being particularly stressful. Doctors often need to make difficult ethical judgements, balancing conflicting demands, for example, between the need to maintain confidentiality versus the requirement to report abuse. They are often powerless to cure and limited in their ability to minimise suffering, limitations that patients and their families are not always immediately willing to acknowledge. Doctors are constrained by standards of behaviour, especially with regard to sexual conduct, that are more exacting than those applied in most other professions. Those who are professionally isolated, especially solo practitioners working in country areas, are at high risk. Female practitioners face role strain having to strike a balance between the demands of work and family.
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Stressors on general practitioners include the everyday difficulties of running a practice, criticism of the profession in the media, having to take responsibility for difficult clinical decisions, and living up to the high ethical standards expected of members of the profession.
Barriers to care
People suffering drug and alcohol problems often deny their illness. The stigma attached to mental illness makes it shameful to acknowledge the problem. The man who needs to be in control will find it hard to admit that he has a problem requiring someone elses assistance. The competitive person may feel humiliated at having to acknowledge his or her own vulnerability. The man who isolates his affect and habitually uses the defence of reaction formation may be unable to recognise his emotional symptoms or to accurately describe them.
Doctors may tend to deny their problems and those of their colleagues.
Denial of mental illness extends to our inability to recognise when colleagues are suffering. We tend to identify with them and collude with their minimisation of problems. Even when we recognise that a colleague has a problem, we may be reluctant to approach him, and feel bound not to dob him in. Doctors make difficult patients. It is easy to assume that they know everything about the problem and so neglect to educate them adequately about their illness and its treatment. They often present late. Those with drug and alcohol problems may only present to treatment when under pressure to do so from a professional body. They are frequently non-compliant and often discharge themselves from inpatient care against medical advice. Regular urine drug screens are often necessary to ensure abstinence from substance abuse.
Administrative structures
A number of medical schools now provide counselling services for students and assign mentors with whom students can discuss problems in confidence. Specific training is given in dealing with death and dying, and with the difficult patient. The idea of screening for medical students at risk of developing emotional problems is fraught with difficulties. Those who are more anxious are often more empathic with patients and less likely to blame others for their mistakes. Moreover, any method of screening runs the risk of being abused as a vehicle for discrimination against minority groups. Doctors health advisory services have been set up in all states.These provide confidential advice, as well as assessment and referral services. Referrals may come from doctors themselves or from their colleagues. Treatment is coordinated by a senior general practitioner and delivered by senior specialists.
Doctors health advisory services provide confidential advice, as well as assessment and referral services.
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Negative attitudes to admitting ones own vulnerability and a tendency to denigrate those who run into difficulties have been prevalent within training institutions, but may be beginning to change. Intern year was often a period of initiation in which new graduates were given considerable clinical responsibility and left to either sink or swim, often with deleterious consequences for patients. A sort of gallows humour is a feature of training hospitals and is certainly an adaptive way of coping. Unfortunately, some people fail to realise where the joke ends. One of the commonest defences against the sort of denigration that is inflicted on junior doctors is the claim that it was only a joke.
7. Get your own general practitioner. Do not self-treat and never self-prescribe. Let your general practitioner coordinate your care. Do not fragment it by making specialist referrals yourself.
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Chapter 26
Consumer and carer perspective
Colleen Chard Laurel Sandilands Linda Urquhart
We have included some vignettes from our life experiences to personalise this workhowever, the underlying theme of the article is that despite the illness or the labels used to describe it, we are still people. Therefore, what we ask of our general practitioner is most often the same as that asked of everyone in the community.That is, to be treated with respect and express a willingness to help whatever the presenting problem.
People with mental illnesses ask to be treated with respect by their general practitioners.
I need to know that I can approach a GP when I am unwell and feel I can talk freely without being feared. I want to be treated with respect, not fear. When I appear to be unwell because of my presenting symptoms, I am not absent from the room. I continue to be aware of other people and their reactions to me. It can be quite hurtful to be discounted as a person because of presenting symptoms. I do not believe that I pose a physical threat to my GP or others in the community. I am a person with an illness and not the diagnosis (label). I should always be treated with respect and fairness and not with fear and uncertainty. In the early stages of awareness of my illness, my first contact with a health professional was with my GP.When my illness first became noticeable, my GP dismissed symptoms as less serious than they were in reality. This caused a significant amount of personal stress for me, because I feared that there was something seriously wrong. The symptoms were real for me; however, I did not understand what was wrong or why it was happening. Nor could I express adequately what was happening to me. It would have been helpful for me if my GP had given me some more time to discuss my concerns. It appears to me that good communication skills are needed to gather all information required to assess an individuals condition. I believe that I need my GP to ask a sufficient number of questions of me and to always encourage good two-way communication. I do not want to suggest that it is the sole responsibility of GPs to communicate with me. I accept my share of the responsibility for good communication; however, at times there are impediments to my ability to communicate well. It is during these times that I need others to assist me to express my need.
Listen to peoples complaints, empathise with how they feel, and be sensitive to verbal and non-verbal cues.
Suffering a mental illness is frightening, frustrating and depressing. People with mental illnesses are often isolated.
Being hospitalised in a psychiatric facility was another significant issue for me. It was scary when I was told that I had to stay in a mental hospital for a number of weeks or months and be isolated from the world outside. I was devastated and I feared my own behaviour. I became angry with people who found it hard to understand that unwell does not equal unaware. It was difficult enough to cope with the outcomes of my own behaviour without others treating me as though I had taken leave of absence from my physical self. The emotional hurt that this has caused me is immeasurable.
Where possible, people generally prefer to be treated in the community rather than in a hospital.
I felt a deep sadness about what was happening to me. I knew that each time I became unwell my interpersonal relationships would suffer. I would lose so much in terms of love, security and
270 Consumer and carer perspective
acceptance of those I cared about. The fear of the illness that was created by these consequences caused me to feel absolute terror. Underlying the terror, I am sure there was a deep sadness, which remains with me now. It was not at all like when I suffered a serious physical illness. Certainly, I might have been going into hospital to have my kidney removed, but my loved ones still loved me and I didnt feel as though I would quite likely lose my family life as I knew it. I sometimes do not have control over my own thoughts, or control of events that are seemingly happening around me. Although these episodes can be infrequent, the effects on me, both personally and emotionally, are no less devastating. Hospitalisation used to be the most common outcome. However, with the advent of community mental health caseworkers and better relationships with GPs, early intervention can satisfactorily stop symptoms snowballing to the point where hospitalisation becomes the outcome. At times, I am unable to concentrate as too many thoughts are entering and rushing through my mind. Everything seems very important, I do not sleep, I do not eat, and I talk a lot. Life seems better for a while. It makes a tolerable change from being depressed. But then, so quickly, it can all escalate and it is like a roller coaster ride that I cannot get off. I do not know at what point I finally lose touch with reality, because it all happens too fastthe thoughts, the actions, the fears, the hospital, the end of life as I have grown accustomed to it yet again. I suffered a loss of my own standard of living. After my first psychotic episode, I feared extending myself too much in case I became ill again. I was worried about returning to work in case it added stress, which caused me to become unwell again. Each time I became unwell I would suffer both financial and emotional losses. As a coping mechanism, I set up my life so that I had less to lose. This form of control enabled me to feel safer with the illness. My husband had great difficulty coping with the nature of my mania and also its periodical reoccurrence. He always hoped that each episode was the last. Eventually it became too much for him and we separated. As my illness also affects my ability to hold down regular, fulltime employment, both of these factors have affected my standard of living. I have also lost contact with a lot of people to whom I was close.There is a tremendous amount of personal loss incurred as a result of periodic bouts of severe mental illness, which includes behaviour so extreme that people around me often never forgive or forget.
People with mental illness have often suffered significant losses, including jobs, financial security and personal relationships.
Involve the family and friends of people with mental illness in treatment. Educate them about the illness.
Relationships with people outside of my immediate family also suffered due to my illness. Some people reacted to me by withdrawing physical and emotional contact. When my boyfriend of three years heard about my illness I found he didnt ring me as often. When he visited me in hospital he said to me, So what have they brainwashed you into thinking you have exactly? When I told him of my condition an uncertain look came to his face and I realised he had
A Manual of Mental Health Care in General Practice 271
trouble accepting my illness. From that point onwards we didnt see each other as often and he didnt phone.
People may react to those with mental health problems by rejection, fear, anger or criticism.
There were people outside my family whom I perceived reacted towards me with fear and uncertainty. When new neighbours moved in next door to me they called to ask me Are you really crazy? They had apparently found out from someone that I had a mental diagnosis. They had called to ascertain whether I was someone that they should be cautious of. Most people in the community know little about mental illness. The little that is known is built on assumptions and misinformation. It is difficult to reassure people who have an uninformed opinion of people with mental illness. If there were a way to better educate the wider community about mental illness, it would no doubt benefit mental health consumers. Due to a lack of understanding of my illness, people generally assumed that I could no longer do many things for myself. After she found out about my illness my mother often said to me that she hoped one day I would wake up and get more involved in doing the housework. Actually, she didnt let me do any of the housework, because she seemed to think that I could no longer do things for myself. However, when she fell sick I ran the household for a week. I cooked dinner, did the dishes, vacuumed and did the laundry. There appear to be negative attitudes in the community towards people who appear to be physically fit and yet do not hold a full-time job. People look at me as though I chose to do nothing and will not find work because for much of the time there are no external signs of my illness. On the telephone, a friend of mine asked whether I was employed. When I replied no, they responded with a comment, It is unfortunate you havent got a job.You could get a job if you really tried. I explained that my illness prevented me from working, but despite my efforts, they could not understand this and went on to call me lazy.
People with mental health problems want to be able to discuss their problems with their general practitioners.
What helped?
I value caring and consistent attitudes and behaviours towards me. I need to feel that I am important. I need to know that I will be treated the same way before, during and after onset
272 Consumer and carer perspective
of my illness. I need to be treated like a person and not have my self-esteem eroded. I need to feel that I am important, but when I tell people that I have schizophrenia, they never want to talk about it. I would love somebody to say Oh, thats interesting, tell me about it. I need my treating physician to be willing to address the mental level of illness, not just the physical and vice versa. That is, sometimes when I have a physical ailment it is too easy to explain this away as psychosomatic. At other times when the symptoms are psychiatric, my physician will seek a physical cause. I need this to be acknowledged so that I can work with my treating doctor to achieve early intervention for episodes of my illness.
People with mental illnesses appreciate being able to discuss their illness with their general practitioners, getting information about it from them. Box 26-1: Three stages of illness
Symptoms leave me in the same order they came. I have spent years at various stages, but now I spend a few days at most and experience only the first three stages. The first stage can appear easily, after I become overly tired or have been exposed to large groups of demanding folks with whom I feel uncomfortable. I have learnt to watch for this stage and then to examine my recent environment. Getting more sleep, in conjunction with some quiet, and a low sugar diet seem to aid in restoring the peace. Sometimes I go into the second stage, which can easily scare me. The fear alone exacerbates my condition into the third stage. Physical illness can trigger many miserable days at this level of existence. In all stages, but especially this stage, keeping calm is important. It is very important that I talk to others. People who have helped in earlier crises can remind me of things I can do to regain control. Sometimes it really helps for people just to acknowledge that I am feeling uncomfortable, and even though they believe it will pass, they have empathy for what I am feeling.They do not try to argue me out of my feelings, but comfort and guide me1.
Lovejoy M. Recovery from schizophrenia. Hospital and Community Psychiatry 1984; 35:8.
A Manual of Mental Health Care in General Practice 273
People may pick up non-verbal cues that suggest that the general practitioner is not listening.
When I spoke to one particular doctor, his body language suggested to me that he wasnt listening. He kept fiddling with his pen in a nervous sort of way as I was speaking (see also Box 26-2).
There appears to be significant social stigma associated with mental illness. Community attitudes toward people with a mental illness make it difficult for me to move freely in society. Not only do others fear my illness, but I also fear it. It creates a barrier for me. I cannot change the attitudes of everybody in the community and, as yet, the illness I have has been resistant to change.This is not to say that I am unwell all the time. In reality, I am well most of the time, and people would not know that I had a mental illness at all.
Conclusion
Persons diagnosed with a mental illness have the same basic needs as everyone else in the community. It is important for people with a mental illness to have good rapport with their GP. It is also important for GPs to have an understanding of mental illnesses, appropriate medications and their effects. Most importantly, we need to have a GP with a caring and approachable manner and a willingness to help at all times, especially when we are unwell. It is also important to be aware of the power of labels in our society. It is better to relate to people with mental illness as individuals, not as schizophrenics or obsessivecompulsive, etc. The sooner the community is more informed and educated about mental illness the better. We do not refer to people with a physical complaint by some label. It is unlikely that you will hear about a diabetic thief, but you may hear about a schizophrenic shoplifter. Labels imply that others with the same label will always behave in the same way and this is not the case. I am a person foremost, and then I am simply an individual who seeks as normal a life as possible and my deserved place in society.
Lovejoy M. Recovery from schizophrenia. Hospital and Community Psychiatry 1984; 35:8.
274
Further information
Training course
SPHERE program
The SPHERE program comprises four components: a case-identification system designed specifically for use in primary care; an initial four-seminar training program for managing anxiety and depression; a 12-month disease management program for depressive disorders; and the provision of ongoing educational and practice support. For general practitioners who have completed the initial training program, a further series of seminars is offered on cognitive behavioural treatments, chronic fatigue and chronic pain, geriatric depression and adolescent mental health problems. The program has been developed within the Academic Department of Psychiatry, St George Hospital and Community Health Service, Kogarah, NSW1.
Essential texts
1. Writing group. Therapeutic Guidelines: Psychotropic Version 4, 2000. North Melbourne, Therapeutic Guidelines Ltd, 2001. Since drug treatments change so rapidly, you need to get each new edition as it becomes available.
2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington, DC, American Psychiatric Association, 1994. This is the definitive guide to diagnosis.
Reference texts
1. Treatment Protocol Project. Management of Mental Disorders. 2nd ed. Sydney: World Health Organization Collaborating Centre for Mental Health and Substance Abuse, 1997. This comprehensive reference in two volumes covers the recognition and treatment of mental disorders. It contains resource materials, including interview schedules and assessment instruments to aid management decisions and to monitor progress, plus educational handouts and homework exercises for patients.
2. Bloch S, Singh BS. Foundations of Clinical Psychiatry. Second Edition. Carlton South, Melbourne University Press, 2001. This is a succinct and well-written textbook of psychiatry. 3. Keks N, Burrows GD eds. MJA Practice Essentials Mental Health. North Sydney, NSW: Australasian Medical Publishing Company Limited, 1998. This is a succinct but comprehensive guide to assist general practitioners to deliver psychiatric care in the community.
Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T, Naismith S, Koschera A. Treating Depression and Anxiety in General Practice:Training Manual. Kogarah, NSW: Educational Health Solutions, 1998.
A Manual of Mental Health Care in General Practice 277
SPHERE - GP
Female
Male
Date of Birth
Day Month Year
Postcode
We would like to know about your general health. For ALL questions, please fill in the appropriate response circle. Please fill in the circles like this:
Over the past few weeks have you been troubled by:
never or some of the time a good part of the time most of the time never or some of the time a good part of the time most of the time
1. Headaches? 2. Feeling irritable or cranky? 3. Poor memory? 4. Pains in your arms or legs? 5. Feeling nervous or tense? 6. Muscle pain after activity? 7. Waking up tired? 8. Rapidly changing moods? 9. Fainting spells? 10. Nausea? 11. Arms or legs feeling heavy? 12. Feeling unhappy and depressed? 13. Gas or bloating? 14. Fevers? 15. Back Pain? 16. Needing to sleep longer? 17. Prolonged tiredness after activity?
18. Sore throats? 19. Numb or tingling sensations? 20. Feeling constantly under strain? 21. Joint pain? 22. Weak muscles? 23. Feeling frustrated? 24. Diarrhoea or constipation? 25. Poor sleep? 26. Getting annoyed easily? 27. Everything getting on top of you? 28. Dizziness? 29. Feeling tired after rest or relaxation? 30. Poor concentration? 31. Tired muscles after activity? 32. Feeling lost for words? 33. Losing confidence? 34. Being unable to overcome difficulties?
Have you recently: 35. thought that you should cut down on alcohol or addictive drugs? 36. had a friend, relative or doctor suggest that you should cut down on alcohol or addictive drugs?
No
Yes
Adapted from: Hickie I, Scott E, Ricci C, Hadzi-Pavlovic D, Davenport T, Naismith S, Koschera A. Treating depression and anxiety in general practice: training manual. Kogarah, NSW: Educational Health solutions, 1998. Note:This example is provided for your information only. Original copies of this form can be obtained from Educational Health Solutions, Suite 13, 3rd Floor, St George private Hospital and Medical Complex, 1 South Street, Kogarah, NSW 2217. These forms can then be sent to the above address to be analysed. Alternatively, a CD-ROM is available for their analysis.
278 Appendices
Folstein MF, Folstein SE, McHugh PR. Mini-Mental State: a practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975 12: 189-198.
A Manual of Mental Health Care in General Practice 279
MINI-MENTAL STATE
Patient: Examiner: . Date: .. Max. Score SCORE
5 5 ( ) ( )
Orientation
What is the (year) (season) (date) (day) (month)? Where are we: (state) (city) (suburb) (hospital) (floor/ward)?
3 ( )
Registration
Name three objects: one second to say each. Then ask the person all three after you have said them. Give 1 point for each correct answer. Then repeat them until he learns all three. Count trials and record. Trials =
5 ( )
3 ( )
Recall
Ask for the three objects repeated above. Give 1 point for each correct.
Language
9 ( ) Name a pencil and watch (2 points) Repeat the following: No ifs, and or buts. (1 Point) Follow a three-stage command: Take a paper in your right hand, fold it in half, and put it on the floor. (3 points) Read and obey the following: CLOSE YOUR EYES (1 point) Write a sentence (1 point) Copy design (1 point) Total score: .. (Maximum score = 30) ASSESS level of consciousness along a continuum: 30 Alert Drowsy Stupor Coma
280
Appendices
281
Exhale
Place both hands across the upper abdomen, just below the rib cage, with the fingers of one hand just touching the fingers of the other hand. Breathe in through your nose. As you breathe in, the fingers will move apart. 3. Slow breathing exercise When people are anxious they tend to over breathe. This then worsens the anxiety and can cause a number of physical symptoms: dizziness, chest pain, tingling in the fingers, a choking feeling, rapid heart rate, cold sweats, nausea, muscle tension and fatigue. This exercise helps you to slow your breathing down to a normal rate. Take a normal diaphragmatic breath. Hold your breath for 10 seconds. Breathe out. As you do so, say the word relax. Then breathe in and out in six-second cycles, three seconds in and three seconds out. Say In, two, three as you breathe in, and Relax, two, three as you breathe out. After a minute (10 breaths), hold your breath for 10 seconds and repeat the cycle. Do the exercise for around five minutes. 4. Check your rate of breathing On completion of the exercise, record your breathing rate again.
282
Appendices
283
Appendix 6 Self-hypnosis
Self-hypnosis can help you take your mind off your things you are worrying about and make you aware of things in your environment that can help your body to relax and make you feel safe. The more you practice it, the better you will get. Say 5 things you can SEE around you. Say 5 things you can HEAR around you. Say 5 things you can FEEL in your body. Say 4 things you can SEE around you. Say 4 things you can HEAR around you. Say 4 things you can FEEL in your body. Say 3 things you can SEE around you. Say 3 things you can HEAR around you. Say 3 things you can FEEL in your body. Say 2 things you can SEE around you. Say 2 things you can HEAR around you. Say 2 things you can FEEL in your body. Say 1 thing you can SEE around you. Say 1 thing you can HEAR around you. Say 1 thing you can FEEL in your body. It does not matter if you use the same things to see, feel or hear when repeating the exercise. At the end of the exercise, take a deep breath in and slowly out again, saying the word calm.
284
Appendices
Sunday
Monday
Morning
06000900
09001200
Afternoon
12001500
15001800
Evening
18002100
21002400
R = rating of pleasure or satisfaction. Rate your level of pleasure in doing things that you enjoy. Rate your satisfaction in fulfilling obligations and duties that you need to perform. Use a scale of 0 (= no pleasure or satisfaction) to 10 (= high level of pleasure or satisfaction).
285
286
Appendices
Appendix 9 Recording feelings, automatic thoughts and the situations in which they arise
People often talk to themselves mentally. However, they are not always aware of this self-talk. It is useful to identify your self-talk at times when you are experiencing unpleasant feelings. You can then examine and, when appropriate, challenge these thoughts. The best approach is to record your feelings and thoughts near to the time that you experience them. Draw three columns on a piece of paper. In the first column record the situation you are in. In the second describe the feeling. In the third, write down your automatic thoughts. Some words used to describe feelings include: angry, annoyed, anxious, ashamed, blue, depressed, devastated, disappointed, disgusted, down, elated, embarrassed, frustrated, guilty, happy, humiliated, insecure, irritable, looked down on, miserable, nervous, sad, scared, terrified, unhappy, unloved. The thoughts that you particularly want to identify are those that give a negative personal meaning to the situation in which they arise. For example, a man feels miserable when he fails to get the job that he applied for. The voice in his head is saying, Im a failure. Some thoughts are predictions about what the event means for the future. For example, the man mentioned above may think, Now I will never get a job. Others reflect on how we think others will react to us, for example, Everybody will think I am a fool. For the purposes of this exercise, some thoughts do not need to be recorded.Thoughts that are descriptions of how you feel should be recorded as feelings (for example,I feel embarrassed). Descriptions of your thinking or experience should not be recorded either (for example, I could barely think straight, it was so stressful). Instead, try to recall the thought itself and record that (for example, I will never be able to get this right).
Feeling miserable
Thought Im a failure. Everybody will think Im a fool. I will never get a job. Im a bore. He dislikes me and thinks Im unattractive. I will never be popular.
287
Examination procedure
Either before or after completing the examination procedure observe the person unobtrusively, at rest (e.g. in the waiting room). The chair to be used in this examination should be a hard, firm one without arms. Ask the person whether there is anything in his or her mouth (e.g. chewing gum) and if there is, to remove it. Ask the person about the current condition of his or her teeth. Ask the person if she or he wears dentures. Do teeth or dentures bother the person now? Ask the person whether she or he notices any movements in mouth, face, hands or feet. If yes, ask to describe and to what extent they currently bother the person or interfere with his or her activities. 1 Have the person sit on chair with hands on knees, legs slightly apart and feet flat on the floor. (Look at entire body for movements while in this position.) 2 Ask the person to sit with hands hanging unsupportedif male, between legs, if female and wearing a dress, hanging over knees. (Observe hands and other body areas.) 3 Ask the person to open mouth. (Observe tongue at rest.) Do this twice. 4 Ask the person to protrude tongue. (Observe abnormalities of tongue movement.) Do this twice. 5 *Ask the person to tap thumb, with each finger, as rapidly as possible for 1015 seconds; separately with right hand, then with left hand. (Observe facial and leg movements.) 6 Flex and extend the persons left and right arms (one at a time), noting any rigidity. 7 Ask the person to stand up. (Observe in profile. Observe all body areas again, hips included.) 8 *Ask the person to extend both arms outstretched in front with palms down. (Observe trunk, legs and mouth.) 9 *Have the person walk a few paces, turn, and walk back to chair. (Observe hands and gait.) Do this twice. * Activated movements Note: A detailed scoring chart for the AIMS can be found in Guy W. ECDEU Assessment Manual for Psychopharmacology. Washington DC: US Department of Health, Education and Welfare, 1976: 534-537.
288
Appendices
4. Past psychiatric history The following are commonly associated with sleep disturbance: depression panic disorder mania generalised anxiety disorder post-traumatic stress disorder anorexia nervosa schizophrenia 5. Collateral history from spouse or partner People with sleep apnoea will typically have episodes of snoring that grow in volume until interrupted by a period of apnoea (see below). The partner may provide the history, clarify any stressors or other precipitants, and confirm the persons alcohol and drug history. 6. Sleep diary The commonest cause of daytime sleepiness is not getting enough sleep, something that the person may not be aware of until asked to document it. The diary may also uncover other problems in sleep hygiene (see below).
2. Disrupted sleeping habit Making a sleep diary will often indicate that the person, because of work, domestic and social commitments, simply does not allow enough time for sleep. Sleeping-in over the weekend may further exacerbate the problem. Similarly, many people develop disrupted sleep in the face of stress. The pattern may then continue even after the stress has been resolved. Treatment: Improve sleep habit (see guidelines for improving the sleep habit, Table 14-3)
3. Disorders of the sleep/wake cycle People at risk of these disorders include those travelling frequently across different time zones, for example, airline staff, shift workers, and people with chaotic sleep patterns. There is considerable variation in the ability of individuals to adapt to these changes. Treatment: Education (see Table 14-3)
4. Insomnia due to a physical condition Treat the underlying condition There may be a coexistent mental disorder (e.g. depression or anxiety).
290
Appendices
5. Insomnia due to a mental disorder Treat the primary disorder. a) Adjustment disorder This is probably the commonest cause of sleep difficulties among people presenting to general practitioners. The disrupted sleep patterns may persist after the stress has been resolved. Major depression is often accompanied by early morning wakening, but may present with any of the patterns of insomnia. Sometimes depression is associated with an increase in sleep time. b) Anxiety disorders (panic disorder, generalised anxiety disorder, post-traumatic stress disorder) The most typical pattern is difficulty getting to sleep. People suffering posttraumatic stress disorder may suffer nightmares of the traumatic event. c) Mania There is, typically, a decreased need for sleep d) Schizophrenia The sleep pattern is often disrupted in acute psychosis. People with chronic schizophrenia may have a reversed sleep cycle, sleeping through the day and staying awake through the night. 6. Specific sleep disorders a) Sleep apnoea An apnoeic episode occurs when there is a cessation of airflow for greater than 10 seconds. The diagnosis of sleep apnoea requires at least five episodes per hour or 30 overnight. In central sleep apnoea, respiratory effort stops; in obstructive sleep apnoea, airflow ceases despite an increase in respiratory effort.The apnoeic episodes end when the person is aroused from sleep. The person may be unaware of this disrupted sleep pattern. Complications include cardiac arrhythmias, hypertension, pulmonary hypertension and sudden death. It has been estimated that up to 40 per cent of people presenting with excessive daytime sleepiness may suffer from sleep apnoea. The condition most commonly affects middleaged or older men. Obese men are at higher risk (Pickwickian syndrome). Sufferers may complain of tiredness and an inability to stay awake during the day, but may not report problems with sleep. The spouse may describe loud snoring, gasping, and apnoeic episodes. There may be morning headaches and depression. You may need to refer the person for sleep studies. These include measurements of airflow, ECG, EEG and electromyogram recordings. Some centres require referral from a respiratory physician. Treatment includes the avoidance of medications or substances that depress respiration, including alcohol and sedative anti-depressants. Various mechanical devices and surgical procedures have been developed to alleviate obstruction. b) Narcolepsy This is a rare condition affecting around four in 10,000 people that is caused by the frequent intrusion of periods of REM sleep during normal waking hours. Symptoms include daytime sleepiness, sleep attacks, cataplexy (a sudden loss of muscle tone), hypnagogic hallucinations, sleep paralysis (being unable to move on waking) and, rarely, blackouts that are sometimes associated with automatic behaviours similar to dissociative episodes (e.g. travelling somewhere and then forgetting how one got there). Onset is usually before the age of 30. It is potentially dangerous because of the risk of accidents. Investigations include sleep studies, which reveal the rapid appearance of REM periods after the onset of sleep (within 10 seconds). Treatment involves taking forced naps regularly during the day, the use of stimulants (amphetamine or methylphenidate) and tricyclic antidepressants for cataplexy.
A Manual of Mental Health Care in General Practice 291
Cox JL, Holden JM, and Sagovsky R. Detection of postnatal depression: development of the 10-item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry 1987; 150:782-786.
1
292
Appendices
294
Appendices
Reproduced with permission of the author, GJ DuPaul, Program Coordinator, School of Psychology, Lehigh University, 111 Research Drive, Bethlehem PA 18015. From DuPaul GJ, Power TJ, Anastopoulos AD, Reid R. ADHD Rating Scale-IV: Checklists, Norms and Interpretation. New York: Guilford, 1998.
1
295
Index
A
Abnormal Involuntary Movement Scale (AIMS) Appendix 10, 288 acting out definition of, 97 in antisocial personality disorder, 229 adjustment disorder in children and adolescents, 257 with depressed mood, 130 adolescent mental health problems. Seechild and adolescent mental health problems agoraphobia, 145146 treatment of by exposure to the feared situation Appendix 8, 286 akathisia, 110 alcohol abuse. See alsosubstance abuse disorders complications of, 169170 physical complications, 169 psychiatric complications of, 169 withdrawal, 169 alexithymia, 165 amisulpride. See antipsychotics, atypical anhedonia definition of, 127 anorexia nervosa, 242244 Calculation of Body Mass Index (BMI), Table 24-3, 244 antidepressants, 112122 changing, Table 13-4, 120 choosing which, Table 13-3, 119 drug interactions with the newer, Table 13-2, 117 reasons for failure to respond to, Table 14-4, 135 antimanic drugs, 122126 antipsychotics atypical, 112 features of, Table 13-1, 114115 traditional, 109 antisocial personality disorder, 228 anxiety definition of , 253 drugs that can cause, Table 17-8, 164 physical illnesses that can cause, Table 17-6, 163 anxiety disorders, 141149. See alsoindividual disorders differential diagnosis of, 142 formulation, 142 in children and adolescents, 253255 symptoms of, Table 15-1, 141 treatment non-specific approaches, 142 attention-deficit/hyperactivity disorder (ADHD), 246248 rating scale, Appendix 13, 295 automatic thoughts and feelings Appendix 9, 287 avoidant personality disorder, 230
B
behavioural assessment, 78 benzodiazepines, 125 Better outcomes in mental health care initiative, 5 beyondblue, 5 bipolar disorder, 130, 213. See alsopsychotic disorders body mass index (BMI) calculation of, Table 24-3, 244 borderline personality disorder, 225228 bland affect in, 227 limit setting in treatment of, 227 use of counselling and problem solving in treatment of, 226 boundary issues, 11 bulimia nervosa, 244 Calculation of Body Mass Index, Table 24-3, 244
C
Calculation of Body Mass Index (BMI) Table 24-3, 244 cannabis, 171 carbamazepine, 124 carers, 269 experience of, 269 of people with psychosis, 219 case-conferencing project, 6 child abuse, 257259 child and adolescent mental health problems, 233264. See alsospecific conditions assessment of, 234235 context of development stage, 233 social milieu, 233 epidemiology of, 233 normal developmental goals, Table 24-4, 262 chlorpromazine. Seeantipsychotics: traditional chronic fatigue, 179 circular causality in family assessment, 43 classical conditioning. Seelearning theory clozapine. Seeantipsychotics, atypical cognitive behavioural therapy (CBT), 8390 cognitive errors, 84 cognitive triad, 83 five-column technique, 85 Table 10-2, 86 in sexual therapy, 11 three-column technique, 85 two-column technique, 86 Table 10-3, 88 underlying assumptions, 84 vertical arrow technique, 8687 Table 10-4, 89
297
conduct disorder, 248249 confidentiality, 14 Consultation-Liaison in Primary Care Psychiatry Project (CLIPP), 6 consumers, 269275 experience of psychotic illness, 270 GPs reaction to, 272 message to GPs, 269 others reactions to, 271 what does not help, 273 what helps, 272 controlled breathing exercises, 79, Appendix 4, 282 conversion disorder, 175. See alsosomatoform disorders, unexplained physical symptoms counselling, 53 advice and, 55 and problem solving, 79 and structured problem solving, 53 versus crisis intervention, 51 countertransference and boundary violations, 11 defined, 11 in response to a self-harming patient, 206 in sexual therapy, 12 in treating people with physical symptoms, 10 in treatment of people with personality disorders, 223231 crisis intervention, 52 versus counselling, 51 culture and mental illness, 35 definition of, 35
D
daily activity schdule Appendix 7, 285 dangerousness assessment and management of, 32 debriefing, 56 defence mechanisms. See alsoindividual defences; See alsopsychodynamic assessment immature, 102 mature, 103 narcissistic, 102 neurotic, 102 splitting, 226 delirium, 155156 drugs used to manage, Table 17-1, 156 delusional disorder, 213. See alsopsychotic disorders dementia, 156161 advice for carers of people with, Table 17-4, 161 complications of, Table 17-3, 158 diagnosis, 155 differential diagnosis, 157 reversible causes of, Table 17-2, 157 treatment of, 158161
298 Index
denial definition of, 101 in bereavement, 57 in histrionic personality disorder, 229 in psychotic illness, 222 of serious illness, 73 dependent personality disorder, 231 depression adjustment disorder with depressed mood, 130 as a response to physical illness, 128 child and adolescent, 250253 compared with grief, 59 diagnosis of, 129 differential diagnosis, 130 drugs that can cause, Table 17-7, 163 dysthymia, 129 educating people about, Table 14-2, 133 formulation, 130 major depression, 129 people at risk, Table 14-1, 129 physical disorders that can cause, Table 17-5, 162 post-partum, 139140 psychotic, 130, 213. See alsopsychotic disorders treatment general principles, 132 non-specific interventions, 132 pharmacological, 134 underlying assumptions that predispose to, Table 10-1, 87 desensitisation, 7980 Figure 9-3, 80 devaluation in borderline personality disorder, 226 diagnosis difference between formulation and, 21 dialectical behaviour therapy (DBT) in treatment of borderline personality disorder, 225 disability definition of, 13 displacement definition of, 102 dissociation definition of, 102 dissociative disorders, 201207 diagnosis of, 204 district mental health services, 17 community assessment and treatment teams, 4 extended hours service, 4 mobile intensive treatment team, 4 referral procedures, 3 role of the case-manager, 4 target population, 3 doctors barriers to care of, 267 mental health of, 265268 personality and coping style of, 266 stressors facing, 266
treatment and prevention of mental health problems in, 267268 drug treatments, 109126. See alsoindividual drugs; See alsopharmacological treatments dynamically informed therapy, 99108 dyspareunia, 198 dystonia, 110
G
general practice filters to mental health care in, Figure 1-1, 2 goal setting, 79 grief abnormal, 59 predisposing factors to, Table 7-2, 60 signs of, 59 Table 7-3, 60 and breaking bad news, 6265 six steps in, 62 compared with mourning, 57 counselling, 5765 definition, 57 normal, 5759 versus depression, 59 guilt. See alsopsychodynamic assessment definition of, 100
E
eating disorders, 242246. See alsoanorexia nervosa, bulimia nervosa Edinburgh Postnatal Depression Scale (EPDS) Appendix 12, 292294 Eight Ages of Man, 104 Table 12-1, 104 empathy. See alsopsychodynamic interventions definition of, 105 Erikson Eight Ages of Man, Table 12-1, 104 exposure and response prevention, 79 extrapyramidal side effects, 109
H
habituation, 79 Figure 9-2, 80 hallucinogens, 171 haloperidol. Seeantipsychotics: traditional handicap definition of, 13 heartsink patients, 223 histrionic personality disorder, 229 defences in, 229 hyperventilation, 141 hypnotics, 125126 abuse of, 171 hypoactive sexual desire disorder, 194 hypochondriasis. See alsosomatoform disorders differential diagnosis, 182 formulation of, 183 treatment of, 183
F
false memory the debate, 206 families, 4349 circular causality in assessment of, 43 functioning of, 43 mental illness and, 45 well-functioning, 45 family problems, 43 family therapy contraindications, 47 indications for, 47 techniques of, 45 transference and countertransference in, 47 fear compared with anxiety, 141 feelings recording, Appendix 9, 287 female orgasmic disorder, 197 female sexual arousal disorder, 195 fibromyalgia, 179 five-column technique, 85 fluclopenthixol. Seeantipsychotics: traditional flupenthixol. Seeantipsychotics: traditional fluphenazine. Seeantipsychotics: traditional formulation differences between diagnosis and, Table 2-1, 21 examples of, 2225 factors that make up, Table 2-2, 22 further information essential texts, 277 reference texts, 277 training course SPHERE program, 277
I
idealisation in borderline personality disorder, 225 in narcissistic personality disorder, 228 impairment definition of, 13 impulse control. Seepsychodynamic assessment indigenous people mental health of, 38 intellectualisation definition of, 102 interpersonal psychotherapy (IPT), 9198 assumptions of, 91 beginning phase, 9293 combined with pharmacotherapy, 98 compared with other psychotherapies, 91 four problem areas, 91 general characteristics of, 91 grief, 93
299
interpersonal deficits, 95 middle phase, 93 role disputes, 94 role transitions, 9495 techniques of, 9698 termination phase, 95 training in, 98 interpretation. Seepsychodynamic interventions interview technique, 9 irreversible inhibitors of monoamine oxidase (MAOIs), 117 irreversible monoamine oxidase inhibitor (MAOI) diet sheet, Table 13-5, 123 irritable bowel syndrome, 179
olanzapine. Seeantipsychotics, atypical operant conditioning. Seelearning theory opiate abuse complications of, 170 oppositional defiant disorder, 249250 organic mental disorders, 155164 delirium, 155156 dementia, 156161 other mental disorders due to general medical conditions, 161
P
pain disorder, 175. See alsosomatoform disorders, unexplained physical symptoms panic disorder, 145 paranoid personality disorder, 224225 parenting advice on, 259264 Parkinsonian side effects of antipsychotics, 110 passive-aggression definition of, 102 personality disorders and proneness to stress, 51 antisocial, 228229 avoidant, 230 borderline, 225228 complications of. Seeindividual disorders definition, 223 dependent, 231 histrionic, 229 narcissistic, 228 obsessive-compulsive, 230 paranoid, 224225 schizoid, 225 schizotypal, 225 use of counselling and problem solving in treatment of, 224 pervasive developmental disorders assessment of, 238239 signs of, Table 24-2, 239 pharmacological treatments, 109126. See alsodrug treatments physical illness causing psychological symptoms, 151 mental illness, 151 occuring indirectly as a result of having a mental illness, 152 psychiatric symptoms in response to, 151 relationship with mental illness, 151 positive reinforcement. Seelearning theory post-partum disorders, 139140 premature ejaculation, 198 problem solving, 53. See alsostructured problem solving progressive muscular relaxation, 79, 81, 144 Appendix 5, 283 projection definition of, 102
K
Korsakoff s Psychosis, 170 Kraepelin, Emil, 209
L
learning theory, 7778 classical conditioning, 77 operant conditioning, 77 negative reinforcement, 77 positive reinforcement, 77 punishment, 78 social learning, 78 lithium, 122
M
major depression. See alsodepression male erectile disorder, 196 male orgasmic disorder, 197 mania clinical features of, 213 drug treatment of, 217 marital counselling, 4749 mianserin, 118 Mini-Mental State Examination Appendix 2, 279280 mirtazapine, 122 mismatched libidos, 194
N
narcissistic personality disorder, 228 narcolepsy, 291 nefazodone, 118 negative reinforcement. Seelearning theory neuroleptic malignant syndrome, 111 non-English cultural background assessing people from, 37 interviewing people from, 37
O
obsessive-compulsive disorder, 147148 in children and adolescents, 255 obsessive-compulsive personality disorder, 230 and need to be in control, 230
300 Index
prolonged fatigue, 179. See alsosomatoform disorders assessment of, 180 causes of, Table 19-1, 181 treatment of, 180 pseudoempathy Box 12-11, 107 psychiatric assessment mental state examination, 19 psychodynamic assessment, 99105 defence mechanisms, 101 developmental stages, 104 impulse control, 99 regression, 104 repetition compulsion, 105 self-esteem, 100 shame and guilt, 100 psychodynamic interventions empathy, 105 interpretation, 106 psychoses definition of, 209 psychotic disorders, 209222 assessment of, 211 behavioural treatment of psychotic symptoms, 218 causes of, 210 diagnosis of, 211 differential diagnosis of, 214 division of, 209 epidemiology, 210 family involvement, 219 investigations of, Table 22-6, 222 natural history of, 210 substance abuse in, 221 treatment of, 215219 individual therapy, 221 rehabilitation, 218 relapse prevention, 218 risk assessment, 215 routine review of people with psychotic illnesses, Table 22-6, 222 treatment setting, 215 puerperal psychosis, 140 punishment. Seelearning theory
S
schemas. Seeunderlying assumptions schizoid personality disorder, 225 schizophrenia, 211. See alsopsychotic disorders aetiology, 210 diagnosis, 211 drug treatment of, 215 natural history and prognosis, 210 negative symptoms of, Table 22-2, 212 prodromal symptoms of, Table 22-1, 211 treatment, 215222 schizotypal personality disorder, 225 selective serotonin reuptake inhibitors, 116 self-esteem, 100 self-harming. See alsosuicidality in borderline personality disorder, 226 self-hypnosis, 144, 145, 146 Appendix 6, 284 sexual abuse, 201207 and borderline personality disorder, 227 and dissociative disorders, 201207 cause of sexual dysfunction, 189 child abuse, 257259 sexual aversion disorder, 195 sexual dysfunction assessment of, 186 drugs that cause, Table 20-1, 188 formulation of, 187 reasons for referral, 199 treatment of, 190200 sexual myths, 190 sexual therapy indications and contraindications, 186 practical aspects of therapy, 186 sensate focus, 193 with homosexual patients, 199200 shame. See alsopsychodynamic assessment definition of, 100 sildenafil, 196 sleep guidelines for improving, Table 14-3, 134 sleep apnoea, 291 sleep disturbance disorders of the sleep/wake cycle, 290 due to a physical condition, 290 due to psychiatric condition, 290 narcolepsy, 291 sleep apnoea, 291 treatment of, Appendix 11, 289291 social learning. Seelearning theory social phobia, 147 sodium valproate. Seevalproate solvents abuse of, 171
301
Q
quetiapine. See antipsychotics, atypical
R
reaction formation definition of, 102 reassurance, 9 regression, 104 repetition compulsion, 105 repression in histrionic personality disorder, 229
somatisation disorder, 175. See alsosomatoform disorders, unexplained physical symptoms somatoform disorders hypochondriasis, 182184 prolonged fatigue syndromes, 179182 unexplained physical symptoms, 175182 assessment of, 175, 180 formulation of, 176 treatment of, 177182 specific phobia, 146 SPHERE-GP instrument, 9 SPHERE-GP questionnaire, 128 example of, Appendix 1, 278 SPHERE program, 6 training course, 277 splitting in borderline personality disorder, 226227 stimulants, 171 stress common stressors, Table 6-1, 51 crisis intervention, counselling and problem solving for, 51 definition of, 51 pathways of treatment of people under, Figure 6-2, 52 personality disorder and proneness to, 51 relationship between coping and level of arousal, Figure 6-1, 52 structured problem solving, 53, 68, 177, 182 Appendix 3, 281 in sexual therapy, 191 structured problem solving, Table 6-2, 54 subjective units of distress scale (SUDS), 79 Figure 9-1, 80 substance abuse, 165172. See alsospecific substances assessment of, 165166 diagnosis, 166 formulation, 166 treatment of, 167169 suicidality assessment and treatment of, 27 assessment of, Table 3-1, 29 criteria for allowing a suicidal person to go home, Table 3-2, 30 in children and adolescents, 250253 mental disorders associated with, Table 3-3, 33 repeated self-harm, 29 supportive psychotherapy aims of, 67 definition of, 67 indications for, 67 techniques, 6874
thioridazine. Seeantipsychotics: traditional thiothixene. Seeantipsychotics: traditional three-column technique, 85 tic disorders, 235 abnormal involuntary movements in, Table 24-1, 236 transcultural mental health, 35 migration and, 36 transference defined, 10 in the treatment of people with personality disorders, 223231 trauma effects on memory, 202 tricyclic antidepressants, 113 two-column technique, Box 10-3, 88
U
underlying assumptions, 84 understanding definition, 12 unexplained physical symptoms, 175182
V
vaginismus, 198 valproate, 125 venlafaxine, 122
W
Wernickes encephalopathy, 170
Z
zolpidem, 126 zopiclone, 126
T
tardive dyskinesia, 111 testosterone treatment with, 199
302 Index